UC-NRLF 


B    3    7t,fi    DSH 


ffOLOGY  LIBEAII 


CARE    OF  CB'A. la EiN'¥s 

UNDERGOING 

GYNECOLOGIC  and  ABDOMINAL 
PROCEDURES 

BEFORE,   DURING,   AND  AFTER  OPERATION 


BY 

E.  E.  MONTGOMERY,  A.M.,M.D.,LL.D.,F.A.C.S. 

Professor    of    Gynecology    in    JefTerson    Medical    College;    Gynecologist     to 

Jefferson  and  St.  Joseph's  Hospitals;    Consulting  Surgeon  to  the  Philadelphia 

Lying-in  Hospital,  the  Jewish  Hospital,  the  Kensington  Hospital  for  Women, 

and  the  American  Oncologic  Hospital 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1916 


"  >  <     . 


'  •    ••?»!»•• 


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D 


GI         ^^OIFfC  COAST 

'  •     TO  nj^^^^^t  OEPk 


Copyright,  iqi5,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


PRESS    OF 

W      B      SAUNDERS    COMPANv 

PHILADELPHIA 


LP' 


TO    THE    MANY    LOYAL    AND    DEVOTED   WOMEN  WHOSE 

FAITHFUL  SERVICE  HAS  MADE  GOOD   SURGERY  POSSIBLE 

THIS  BOOK  IS  RESPECTFULLY  DEDICATED. 


743593 


PREFACE 


Every  surgeon,  in  preparing  for  an  unusual  operation,  has 
found  it  difficult  to  decide  just  what  instruments  and  materials 
should  be  selected.  To  the  novice  in  the  operating  room, 
nurse,  or  hitern  every  operation  is  an  unusual  one,  and  with- 
out special  instruction  in  preparation  for  various  operations 
important  instruments  and  articles  will  be  overlooked.  The 
surgeon,  too,  harassed  with  the  care  of  many  patients,  will 
not  infrequently  find  that  in  his  selection  he  has  omitted  some 
things  which  would  have  greatly  expedited  his  work. 

While  convalescing  from  an  operation  last  summer  the 
writer  decided  to  prepare  for  his  assistants  some  tj^Dewritten 
instructions  which,  as  the  work  progressed,  he  found  it  neces- 
sary to  extend,  until  this  Httle  book  is  its  outgrowth.  He  has 
endeavored  to  present  a  chart  which,  if  intelligently  followed, 
will  greatly  accelerate  the  work  of  the  surgeon,  add  to  the 
comfort  of  his  patients,  and  redound  to  the  credit  of  his 
assistants.  His  own  experience  assures  him  that  this  book 
will  prove  valuable  to  the  young  gynecologist  by  making  easy 
his  early  steps  alone  in  the  field  of  pelvic  and  abdominal 
surgery. 

He  takes  this  opportunity  to  express  his  appreciation  of 
the  courtesy  and  generous  co-operation  of  the  publishers;  to 


8  PREFACE 

thank  Mr.  J.  V.  Alteneder  and  IMiss  S.  L.  Clark  for  their  work 
in  the  preparation  of  the  illustrations;  Messrs.  Charles  Lentz 
and  Sons  and  ]\Iiss  Clara  Melville  for  the  loan  of  instruments, 
and  Miss  Nellie  M.  Gandley  for  the  work  of  transcribing. 

If  this  book,  as  it  passes  from  his  hands,  by  lessening  the 
anxiety  of  the  surgeon,  promotes  better  work,  facilitates  the 
labor  of  nurses  and  interns,  but,  above  all,  adds  to  the  comfort 
and  satisfaction  of  the  patients,  the  author  will  feel  well  re- 
paid for  his  efforts. 

E.  E.  Montgomery. 

1426  Spruce  St.,  Philadelphia,  Pa. 
September,  igi6. 


CONTENTS 


GENERAL  PART  page 

On  Admission 1 1 

Preparation  of  the  Field  for  Operation 12 

The  Incision 15 

Closure  of  the  Wound 21 

Dressings 25 

Clinic  Work 26 

Care  of  Patient  During  Operation 27 

After-care 29 

Catheterization 32 

Nourishment 34 

Shock : 36 

Nausea  and  V^omiting 41 

Hemorrhage,  External  and  Internal 42 

Tympanites 45 

Abdominal  Pain  and  Tenderness 48 

Peritonitis 49 

Sepsis 52 

Phlebitis 56 

Ileus 58 

Fecal  Fistula .  60 

ABDOMINAL  AND   PELVIC  OPERATIONS 

Shortening  Ligaments 62 

Salpingectomy — Salpingo-oophorectomy 67 

Ovariotomy 73 

Hysterectomy — Panhysterectomy — Subtotal  Hysterectomy 77 

Intestinal  Resection  and  Anastomosis .  82 

Gastric  Operations 86 

Gastropexy 87 

Gastrotomy 91 

Gastro-enterostomy 92 

9 


lO  CONTENTS 

PAGE 

Gall-bladder  Operations 97 

The  Spleen 103 

Operation  Upon  the  Kidney 105 

VAGINAL  OPERATIONS 

Dilatation  and  Curetment 116 

Trachelorrhaphy 119 

Amputation  of  Cervix 1 23 

Anterior  Col[iorrhai)hy ' 128 

Vesicovaginal  Interposition  of  Uterus;  Watkins'  Operation 130 

Vaginal  Hysterectomy 132 

Perineorrhaphy^;   Posterior  Colporrhaphy;   Rectovaginal  Interposition  of 

Levator  Ani  Muscles 138 


I>JDEX 147 


CARE  OF  GYNECOLOGIC  PAlfltiNTS 


GENERAL   PART 


ON   ADMISSION   OF   THE   PATIENT 

Nurse's  Duties. — On  admission  of  a  patient,  the  nurse 
should  record  the  temperature,  pulse,  and  frequency  of  res- 
piration; secure  a  specimen  of  urine  for  examination,  and, 
if  her  condition  is  in  any  way  unsatisfactory,  should  notify 
the  intern  at  once. 

Intern's  Duties. — Every  operative  patient  should  have 
the  urine  examined,  an  ordinary  blood-count  made,  and  her 
blood-pressure  taken.  A  careful  history  should  be  written, 
and  on  his  visit  the  attention  of  the  visiting  surgeon  directed 
to  her.  A  supranormal  temperature,  anemia,  or  the  appar- 
ent appearance  of  recent  hemorrhage  should  indicate  a  com- 
plete blood-count.  If  she  has  a  vaginal  discharge,  a  smear 
should  be  taken  for  examination  and  cultures  made.  In 
septic  conditions  it  is  wise  to  order  cultures  made  from  the 
blood  and  institute  measures  to  secure  vaccines. 

When  the  date  for  operation  has  been  decided,  the  pa- 
tient should  be  ordered  a  purgative  for  the  morning  preced- 
ing (the  best,  01.   ricini,   fgij)  and  a  soap-and-water  enema 

for  the  night  before.     The  diet  for  the  day  before  should 

II 


12  CARE  OF  GYNECOLOGIC  PATIENTS 

have  as  little  waste  material  as  possible  and  only  hot  water 
on  the  moniiijig  of  Qper£ttio]i,  unless  it  is  to  take  place  late 
in  the  day;,' when, the  .patient  may  be  given  a  little  bouillon, 
clear  soup,  or  a  cup  of  'tzi  Or  coffee  without  milk. 

PREPARATION    OF   THE   FIELD   FOR    OPERATION 

The  held  for  operation  should  be  prepared  by  the  re- 
moval of  the  hair,  either  by  shaving  or  with  a  depilatory. 
The  latter  is  less  objectionable  in  that  the  skin  is  uninjured 
and  no  opportunity  is  thus  afforded  for  skin  infection.  The 
following  prescription  forms  a  very  satisfactory  depilatory: 

Calcii  caustici  pulveri lo.o 

Sodii  sulphid ■ 3.0 

Amyli 10. o 

Pulverize  separately,  mix,  and  keep  in  a  bottle  dry.  When 
desired  to  be  used,  mix  with  enough  water  to  make  a  paste 
and  spread  on  the  surface  about  |  inch  thick  with  a  wooden 
spoon  or  glass  spatula.  When  applied  over  the  vulva  the 
mucous  surface  should  be  previously  painted  with  some  sterile 
oil  as  a  })rotcclion. 

The  entire  abdominal  surface  shoukl  be  deprived  of  hair, 
the  surface  bathed  with  soap  and  hot  water  and  afterward 
with  alcohol.  After  the  surface  has  had  time  to  dry  it  should 
be  painted  with  an  alcoholic  solution  (3.5  per  cent.)  of  iodin 
and  have  a  sterile  dressing  kept  in  place  with  a  bandage. 
This  painting  should  be  repeated  the  evening  before  the 
operation  and  again  after  the  patient  is  brought  to  the  oper- 
ating-table.    After   the   last  painting  has  become  dry,   the 


PREPARATION  OF  THE  FIELD  FOR  OPERATION  13 

entire  surface  should  be  sponged  with  a  gauze  pad  wet  with 
alcohol  to  remove  the  superfluous  iodin  and  prevent  its  in- 
juring any  coils  of  intestine  which  may  escape  and  come  in 
contact  with  the  skin  surface.  This  precaution  may  save 
the  patient  from  desquamation  of  the  intestinal  endothe- 
lium which  would  most  certainly  cause  subsequent  adhe- 
sions and  their  unfortunate  sequelae. 

Should  the  patient  suffer  from  a  condition  which  requires 
immediate  attention,  and  the  requisite  time  for  preparation 
cannot  be  taken,  the  abdomen  should  be  shaved,  then  be 
washed  first  with  gasoline,  subsequently  painted  with  iodin 
solution,  and  then  again  washed  with  alcohol  before  opening 
the  abdomen. 

The  preparations  for  abdominal  incision,  indeed,  for  any 
operative  procedure,  demand  the  utmost  cleanliness  on  the 
part  of  the  surgeon  and  his  assistants.  Every  avenue  for 
the  entrance  of  infection  must  be  rigidly  controlled.  The 
operator  and  his  assistants  must  diligently  wash  their  hands 
and  arms  with  soap  and  hot  water,  using  the  nail-brush  for  a 
period  of  ten  minutes,  even  though  they  expect  to  wear  rubber 
gloves.  Gloves  are  worn  to  protect  the  patient,  not  the 
wearer,  from  infection.  They  must  not  be  an  excuse  for  neg- 
lect of  surgical  cleanliness,  otherwise  it  were  better  not  to 
use  them.  A  glove  may  be  easily  torn  or  punctured  during 
the  operation,  then  neglect  in  cleanliness  may  mean  grave 
danger  to  the  patient.  The  purpose  of  wearing  the  gloves 
is  defeated  when  the  surgeon  uses  the  fingers  of  the  bare  hand 
to  press  in  place  the  fingers  of  the  first  glove  he  puts  on. 


14  CARE  OF  GYNECOLOGIC  PATIENTS 

The  surgeon  and  all  his  assistants  who  have  anything  to  do 


w 


n 


a 
o 


with   handling   instruments,   ligatures,   sutures,   or  dressings 
must  be  gowned,  masked,  and  gloved.     Such  preparations 


THE  INCISION  15 

should  be  preliminary  to  any  manipulation  of  the  material 
to  be  used  in  the  operation.  The  instruments,  suture  and 
ligature  material,  the  dressings,  gowns,  and  all  the  parapher- 
nalia for  the  operation  should  be  carefully  protected  from 
exposure  until  needed. 

Consideration  must  be  given  to  every  step  of  the  pro- 
cedure, and  the  effect  of  any  misstep  appreciated.  The  better 
prepared  the  operator,  the  more  accurately  he  has  planned 
the  procedure,  the  greater  the  efficiency  of  his  staff,  the  better 
will  be  his  ultimate  results  (Fig.  i). 

THE   INCISION 

The  treatment  of  the  great  majority  of  visceral  condi- 
tions within  the  abdomen  demands  an  incision.  The  situa- 
tion of  the  incision  will  depend  upon  the  particular  structure 
involved.  An  incision  for  drainage  may  be  made  directly 
over  the  position  of  an  abscess,  whether  it  arises  from  a  sup- 
purating appendix,  gall-bladder,  or  from  a  local  infection, 
as  in  cellulitis.  The  most  frequent  incisions  will  be  limited 
to  the  median  line,  above  or  below  the  umbilicus.  In  pelvic 
surgery,  either  the  median  or  the  transverse,  known  as  the 
Pfannenstiel,  will  afford  ready  access  to  the  affected  viscera. 
If  the  appendix  is  the  sole  cause  of  the  procedure,  and  espe- 
cially if  it  has  been  the  seat  of  recent  inflammation,  a  right- 
sided  incision  over  the  semilunaris  muscle,  or  l)y  splitting 
the  abdominal  muscles,  is  generally  preferred,  although  the 
appendix  is  readily  reached  through  a  median  opening. 

Instruments. — See  Fig.  2. 


i6 


CARE  OF  GYNECOLOGIC  PATIENTS 


Chromic  and  plain  catgut,  assorted  sizes,  sterile  sheets, 
towels,  and  gowns. 


■    -3 


o  2 


c 


Ml 

C 


.£   o 


c 
o 


£   E 


t:  2 


The  above-named  instruments  are  for  the  mere  incision.    A 
more  extended  list  will  be  named  in  the  individual  operations. 


THE  INCISION 


17 


The  median  incision  is  one  in  the  median  line  below  the 
umbilicus.  The  operator  stands  to  the  patient's  left,  with 
his  assistant  to  her  right.  The  cleft  of  the  vulva  and  the 
umbilicus  are  landmarks  for  the  incision.  With  the  thumb 
and  index-finger  of  the  left  hand  he  makes  the  tissues  tense, 


\ 


Fig.  3. — Median  incision.     Combination  retractor  in  place.     Intestines  walled  back 

with  gauze. 

while,  with  the  scalpel  in  the  right,  the  incision  is  carried 
through  the  skin  and  superficial  fascia  in  the  first  upward 
sweep  of  the  knife;  the  second  sweep  divides  the  aponeurosis, 
and  if  over  the  rectus  muscle  the  latter  is  separated  from  its 
fellow,  and  by  holding  up  the  tissues  with  the  left  hand  the 


i8 


CARE  OF  GYNECOLOGIC  PATIENTS 


deep  fascia  and  the  peritoneum  can  be  opened  without  dan- 
ger to  the  subjacent  coils  of  intestine.  As  soon  as  the  peri- 
toneum is  opened  the  intern  and  surgeon  each  mscrt  a  linger, 
incise  the  peritoneum  the  length  of  the  wound,  and,  if  de- 
sirable, extend  the  latter.  The  nurse  hands  a  long  folded 
gauze  pack,  by  which  the  surgeon  walls  back  the  intestines, 
exposing   the   pelvic   viscera.     The   median   incision   is   em- 


^ 


J 


Fig.  4. — Wound  in  process  of  suture.     Peritoneum  closed.     Aponeurosis  being  sutured. 

ployed  for  the  investigation  of  the  abdominal  contents  when 
the  condition  is  so  obscure  that  pathologic  lesions  cannot 
otherwise  be  determined  fFig.  3).  Such  operations  should 
be  rare.  It  is  also  employed  in  the  treatment  of  inflamma- 
tory conditions  of  the  pelvis,  for  the  removal  of  fibroid  growths, 
for  the  extirpation  of  the  uterus  for  cancer,  and  the  excision 
of  ovarian  growths. 


THE  INCISION 


19 


Pfannenstiel  Incision. — This  incision  can  be  employed 
for  the  removal  of  small  fibroids,  cancer  of  the  body  of  the 
uterus,  to  shorten  the  ligaments,  separate  adhesions,  re- 
move the  appendix,  and  for  other  local  conditions  when 
suppuration  and  active  infection  are  not  present.  The  large 
amount  of  connective  tissue  opened,  which  can  be  protected 


^  ,.-A 


Fig.  5. — Wound  closed. 


with  diflficulty,  makes  its  employment  undesirable  in  suppura- 
tion and  acute  infections  (Fig.  6). 

The  operator,  with  scalpel  in  left  hand,  the  abdomen  made 
tense  by  pressing  its  surface  upward,  with  the  right  makes 
a  slight  curved  incision  convex  upward  across  the  lower 
part  of  the  abdomen,  cutting  through  the  skin,  superficial 
fascia,  and  aponeurosis  to  the  muscle.    As  the  aponeurosis  is 


20 


CARE  OF  GYNECOLOGIC  PATIENTS 


opened,  two  fingers  of  the  right  hand  are  inserted,  drawing 
toward  the  umbilicus,  while  the  incision  through  the  fascia 
is  completed.  Usually  the  apices  of  the  pyramidalis  muscles 
are  firmly  attached  to  the  under  side  of  the  fascia  and  should 
be  cut.  which  permits  the  necessary  exposure  of  the  recti 
muscles.  Two  fingers  are  pressed  against  them  and  the 
tissues  lifted  up,  when  the  peritoneum  can  be  opened  verti- 


Fig.  6. — Pfannenstiel  incision. 

cally.  The  intern  and  surgeon  each  inserting  a  finger,  the 
peritoneum  is  cut  the  length  of  the  wound.  The  structures 
thus  lifted  up,  the  jxTitoncum  can  be  opened  without  danger 
to  the  intestines  without  the  need  of  forceps.  The  intestines 
are  packed  back  with  gauze.  The  packing  should  be  with  a 
piece  of  folded  gauze  of  good  length,  so  lliat  there  will  be  no 
possibility  of  it  being  overlooked  when  the  operation  is  com- 


CLOSURE  OF  THE  WOUND 


21 


pleted.    The  nurse  in  charge  of  the  gauze  should  know  just 
how  many  pieces  have  been  issued,  and  see  that  they  have 


■^ 

^  JHIIJHmHHHp^^ 

1 

p 

K 

•' .  ■••!■  - 

:-^-v. 

X 

'"  -'^M 

^ 

1 

'f 

*** 

% 

1,^ 

^  r 

\ 

Fig.  7. — Wound  closed. 

been  counted  before  the  wound  is  closed  (Fig.  7).  No  gauze 
should  be  placed  in  or  left  in  the  abdomen  except  by  the 
operator  himself. 

CLOSURE  OF  THE  WOUND 
In  order  to  avoid  repetition,  the  closure  of  the.  wound 
and  the  detail  of  after-treatment  will  be  considered  at  once 
for  all  procedures.  The  intra-abdominal  manipulation  hav- 
ing been  completed,  and  gauze  pads  and  instruments  all  ac- 
counted for,  the  ilnal  step  in  the  procedure,  the  closing  of 
the  wound,  is  in  order.  The  skin  surface  should  be  wiped 
dry  and   clean   towels  placed   about   the  wound,   especially 


22  CARE  OF  GYNECOLOGIC  PATIENTS 

where  there  has  been   soilmg  of  the  surface  with  discharges 
from   the  cavity  during  the  course  of  the  operation.     The 
edges  of  the  peritoneum  may  be  seized  with  hemostats  and 
thus  made  more  readily  accessible.     The  nurse  hands  the 
surgeon  a  long  curved  needle  threaded  with  a  No.  i  chromic 
catgut  suture,  with  which  he  begins  at  the  upper  angle  of 
the  wound  and  picks  up  the  peritoneum  of  each  side,  passes 
a  suture,  ties  with  th^ee  turns  of  the  gut,  and  cuts  one  end 
of  the  suture  short;  then  proceeds  to  use  the  suture,  con- 
tinuously closing  the  peritoneum,  so  opposing  its  inner  sur- 
face that  no  raw  edge  is  inv'erted  to  come  in  contact  with  in- 
testine or  omentum  and  thus  afford  opportunity  for  the  oc- 
currence of  adhesions.     Three  ties  are  made  with  catgut  at 
its  completion  at  the  lower  end  of  the  wound.     This  pre- 
caution is  necessary  to  ensure  against  the  knot  slipping  a'nd 
becoming  untied,  which  would  prove  disastrous  in  a  wound 
closed  with  continuous  suture.     The  wound  is  wiped  dry  and 
all  bleeding  vessels  secured.     The  nurse  now  hands  a  round- 
pointed   needle  threaded   with  No.    i    chromic  catgut,   with 
which  one  or  more  sutures  are  taken  in  the  recti  muscles  to 
ensure  their  being  held  in  contact.     A  cutting-edged  needle 
here  might  injure  a  vessel,  which  would  cause  an  accumula- 
tion of  blood  beneath  the  muscle-,  or  the  subsequent  united 
aponeurosis  affording  a.  collection  which  if  infected  endangers 
the  future  healing  and  resistance  of  the  wound.     With  the 
same  sized  chromic  catgut,  but  with  a  long  curved  cutting- 
edged  needle,  the  surgeon  picks  up  the  aponeurosis  or  deep 
fascia  at  one  angle  of  the  wound,  ties  a  knot  with  three  turns, 


THE  PACIFIC  COAST  JUUKinal 
OF  NURSING 


CLOSURE  OF  THE  WOUND  23 

and  with  a  continuous  suture  closes  this  structure  through 
the  length  of  the  wound,  keeping  in  mind  that  it  is  the  most 
important  resisting  structure  of  the  wall.  This  suture  is 
ended  with  a  three-tie  knot.  The  continuous  suture  is  ob- 
jected to  by  many  for  the  reasons  (i)  that  if  infection  occurs 
it  will  follow  the  suture  through  the  entire  wound;  (2)  that  if 
any  portion  of  the  suture  is  injured  or  broken  the  structures 
separate  its  entire  length.  Considering  these  objections 
valid,  for  a  time  I  discontinued  this  method  of  suturing  and 
substituted  the  interrupted  suture,  but  when  infection  oc- 
curred the  catgut  was  slow  in  being  absorbed  or  in  disin- 
tegrating, and  had  to  be  fished  out  before  the  wound  would 
heal,  and  it  is  much  easier  to  catch  one  suture  than  many. 
The  suture  properly  secured  is  unlikely  to  break,  and  where 
ordinary  precautions  are  preserved  the  instances  in  which 
such  sutures  are  infected  or  break  are  infrequent.  The 
many  knots  incident  to  closure  by  interrupted  sutures  are  a 
great  source  of  danger.  In  thick  and  fat  abdominal  walls  it 
is  better  that  the  fatty  or  superficial  fascia  should  be  united 
with  sutures,  as  the  procedure  obliterates  dead  space  in 
which  blood  or  liquefied  fat  may  serve  as  a  nidus  for  infection 
and  cause  discomfort  as  well  as  danger  to  the  future  welfare 
of  the  patient.  These  sutures  should  be  interrupted  and 
of  plain  catgut.  Finally,  with  a  No.  o  chromic  catgut  suture 
the  skin  edges  are  brought  together  by  a  continuous  suture. 
The  precaution  should  be  exercised  that  strong  traction  is*not 
made  on  this  suture,  as  the  skin  is  strangulated  and  may  cause 
infection  or  even  slough. 


24  CARE  OF  GYNECOLOGIC  PATIENTS 

DRAINAGE 

The  question  of  drainage  is  not  so  momentous  a  one  as  it 
was  twenty  years  ago,  and  the  cases  in  which  it  is  considered 
necessary  are  comparatively  infrequent.  The  dependent 
position  of  the  pelvis  makes  the  vagina  the  choice  outlet  for 
drainage  in  woman.  Drainage  through  this  canal  has  the 
additional  advantage  of  not  weakening  the  abdominal  wall, 
so  that  danger  of  hernia  is  decreased.  The  retro-uterine  in- 
cision into  the  vagina  ensures  the  lowest  part  of  the  ab- 
dominal cavity  being  the  seat  of  the  drain,  and  is  conse- 
quently most  effective.  A  vent  in  this  situation  affords  a 
further  advantage,  that  in  extensive  adhesions,  or  where  the 
peritoneum  of  the  pelvis  has  been  much  injured  in  the  opera- 
tion, or  by  previous  inflammation  the  contact  of  the  intes- 
tinal coils  with  such  raw  surfaces  can  be  prevented  by  pack- 
ing the  pelvis  with  iodoform  gauze.  One  end  of  the  gauze 
pack  is  carried  into  the  vagina  and  is  withdrawn  through-  it 
when  its  purpose  has  been  served.  The  best  drain  is  the 
split  rubber  tube,  which  should  be  secured  to  the  vaginal  in- 
cision. Even  where  the  pelvis  is  packed  with  gauze,  espe- 
cially where  drainage  is  desired,  the  gauze  should  be  supple- 
mented by  the  employment  of.  split  rubber  tubes.  The 
gauze  alone  soon  becomes  clogged  with  exudate  and  serves  as 
a  tampon,  rather  than  a  drain.  The  vaginal  drain,  with  the 
patient  in  a  semisitting  pos'ition,  favors  the  most  effective 
drainage  of  the  peritoneal  cavity.  The  cases  are  now  rare 
when  drainage  through  the  abdominal  walls  has  to  be  con- 
sidered for  pelvic  conditions.     In   appendiceal  abscess  and 


DRESSINGS  25 

inflammation  in  the  upper  abdomen  it  would  not,  of  course, 
be  considered  wise  to  afford  escape  through  the  vagina.  In 
general  peritonitis  it  may  be  desirable  to  have  several  open- 
ings for  the  escape  of  the  infectious  material,  for  it  should 
not  be  overlooked  that  the  tendency  is  for  the  drain  to  be 
walled  off  as  a  foreign  body,  and  its  area  of  action  conse- 
quently becomes  very  much  diminished.  The  action  of  the 
drain  is  greatly  promoted  by  placing  the  patient  in  a  semi- 
sitting position  with  the  employment  of  a  continuous  instilla- 
tion of  water  by  the  rectum,  known  as  the  Murphy  drip. 

DRESSINGS 

The  treatment  of  wounds  has  been  of  late  years  much 
simplified,  and  it  is  recognized  that  nature  will  do  her  work 
well  when  the  wound  is  properly  protected.  Care  has  been 
exercised  during  the  operation  to  protect  the  wound  surfaces 
from  contact  with  infectious  material,  and  when,  as  in  in- 
flammatory conditions,  it  has  been  impossible  to  prevent 
such  contact,  it  is  a  good  plan  after  closing  the  peritoneum 
with  a  continuous  suture  to  paint  the  wound  with  a  3.5  per 
cent,  solution  of  iodin  and  dry  the  surface  before  closing  it. 
Cohections  of  blood  in  the  wound  are  prevented  by  hgation 
of  bleeding  vessels  and  the  method  of  suturing.  With  the 
completion  of  the  skin  suturing,  the  wound  and  surrounding 
skin  surface  are  sponged  with  a  50  per  cent,  solution  of  alco- 
hol, and  the  edge  of  the  wound  painted  with  a  3.5  per  cent, 
iodin  solution,  after  which  it  is  covered  with  sterilized  fluff 
gauze  and  a  sterile  gauze  and  non-absorbent  cotton  pad  is 


26  CARE  OF  GYNECOLOGIC  PATIENTS 

held  in  place  by  strips  of  plaster  or,  better,  by  pieces  of  tape 
which  are  secured  to  plaster  on  either  side  of  the  abdomen 
and  tied  across  the  dressing.  The  latter  method  is  prefer- 
able, as  it  affords  easy  access  to  the  wound  without  the  dis- 
comfort incident  to  pulling  off  the  plaster,  or  the  accumu- 
lation of  a  large  quantity  of  the  latter  when  it  is  cut  at  the 
side  of  the  pad  and  new  pieces  covered  over  the  cut  ends. 
In  addition  to  being  neater  in  appearance  and  more  com- 
fortable, it  has  the  advantage  of  being  economic,  which  is  a 
matter  of  importance  in  the  work  of  a  large  hospital.  The 
dressing  is  completed  by  the  application  of  a  well-adjusted 
abdominal  binder,  which  is  pinned  over  the  covered  wound. 
This  bandage  not  only  keeps  the  dressing  in  contact  with  the 
wound,  but  affords  comfort  and  support  to  the  patient  in 

change  of  position. 

CLINIC  WORK 

In  the  clinic  of  a  large  hospital,  where  the  cases  follow 
each  other  in  rapid  succession,  it  is  important  that  each 
person  be  so  drilled  that  he  or  she  will  understand  what  is 
expected  at  each  successive  step  and  be  ready  to  discharge 
the  duties  promptly  and  without  confusion.  Supplies  of 
dressings,  sterile  gowns,  gloves,  and  other  accessories  should 
be  accessible,  but  should  not  be  uncovered  and  exposed  in  a 
room  which  is  occujiied  by  a  number  of  attendants  and  ob- 
servers. After  each  operation  the  table  covering  should  be 
changed  and  the  operator  and  assistants  change  their  gowns 
and  gloves.  Where  a  number  of  operations  are  done  on  the 
same  patient,   especially  when  plastic  operations  are  done 


CARE  OF  THE  PATIENT  DURING  THE  OPERATION        27 

about  the  vulva  and  vagina,  not  only  the  operator  and  in- 
tern but  also  the  nurses  should  change  their  gloves  before 
proceeding  to  the  abdominal  section,  for  it  stands  to  reason 
the  handhng  of  the  needles  and  instruments  by  the  operator 
and  nurses  will  necessarily  lead  to  the  soiling  of  the  gloves 
of  the  nurses,  when  to  handle  sutures  and  ligatures  with 
these  soiled  gloves  for  the  subsequent  abdomina'l  operation 
would  be  prejudicial  to-  the  good  healing  of  the  wound,  even 
did  no  more  serious  result  follow.  All  soiled  pieces  of  gauze 
should  be  removed  from  the  room  before  beginning  opera- 
tion upon  another  patient  and  the  vestiges  of  blood  should 
be  mopped  up.  While  there  may  be  no  danger  to  the  suc- 
ceeding patient  from  the  blood  on  the  floor  of  a  former  one,  it 
is  unseemly  that  an  operating  room  should  have  the.  appear- 
ance of  a  shambles.  As  the  gauze  used  in  the  operation 
must  be  accounted  for,  it  is  evident  that  it  is  unwise  to  have 
the  count  confused  by  some  left  from  a  fomier  operation. 
Perfect  order,  surgical  cleanliness,  and  conscientious  con- 
sideration of  the  interests  of  the  patients  should  characterize 
the  course  of  all  the  participants  of  a  clinic,  whether  the  in- 
dividuals treated  therein  be  rich  or  poor. 

CARE    OF   THE   PATIENT   DURING   THE    OPERATION 

The  room  in  which  the  operation  is  done  should  be  ap- 
propriate for  the  purpose,  well  lighted  and  heated.  The 
patient  should  be  protected  from  drafts,  and  the  abdominal 
viscera  when  the  ca\'ity  is  opened  should  be  packed  back 
with  gauze.     In  a  protracted  operation  the  gauze  or  covering 


28  CARE  OF  GYNECOLOGIC  PATIENTS 

should  be  moistened  with  warm  salt  solution,  and  this  satura- 
tion should  be  repeated  from  time  to  time,  so  that  there  will 
be  no  opportunity  for  the  surface  to  become  dried  or  chilled 
from  the  continued  exposure.  The  moistening  of  gauze 
packs  which  have  been  in  place  for  some  time  will  save  the 
intestinal  endothelium  from  injury.  The  anesthetist  keeps 
the  patient's  pulse,  temperature,  blood-pressure,  and  general 
appea-rance  under  observation,  and  is  prepared  to  institute 
restorative  measures  whenever  they  seem  to  be  indicated. 
It  is  important  that  the  danger-line  should  be  anticipated 
rather  than  to  institute  restorative  measures  only  when 
the  patient  is  beginning  to  succumb.  Strychnin,  ergone  or 
some  aseptic  ergot,  a.n.d  atropin,  should  be  at  hand  for  use 
hypodermically,  and  in  all  cases  where  a  serious  condition 
is  possible,  apparatus  and  material  for  hypodermoclysis  or 
intravenous  injection  should  be  ready.  In  operations  on 
patients  who  are  previously  much  enfeebled  by  disease,  or 
where  the  operation  is  likely  to  be  greatly  prolonged,  the 
condition  of  the  patient  may  be  favorably  maintained  by  em- 
ploying continuous  hypodermoclysis  during  the  operation. 
A  needle  beneath  each  breast,  or  inserted  through  the  chest 
muscle,  into  each  axilla,  connected  by  a  Y-tube  with  a  saline 
reservoir,  may,  under  the  care  of  a  nurse  and  watched  by  the 
anesthetist,  be  stopped  temporarily  or  allowed  to  continue 
according  to  the  exigencies  of  the  case.  Should  the  vitality 
flag  in  spite,  of  these  measures,  or  in  cases  where  they  have  not 
been  instituted,  resort  should  be  had  to  intravenous  injection 
of  a  saline  solution,  using  a  i  per  cent,  solution  of  either  sodium 


AFTER-CARE  29 

chlorid  or  sodium  citrate,  to  which  may  be  added  i  dram  of 
adrenal  chlorid  or  5  grains  of  caffein  citrate.  This  procedure 
may  be  employed  while  the  operation  progresses,  and  |  pint  to 
I  quart  of  the  solution  thrown  in.  In  patients  suffering  from 
shock  the  amount  of  ariesthetic  should  be  kept  at  a  minimum, 
and  it  is  better  that  the  patient  should  feel  the  procedure,  and 
thus  through  stimulation  of  her  nerve-centers  promote  reac- 
tion. 

AFTER-CARE 

The  bandage  having  been  appUed  to  maintain  the  dressing 
in  place,  the  patient  should  be  covered  with  blankets  and  pro- 
tected from  exposure  while  being  transported  to  her  room. 
When  much  shocked,  artificial  heat  should  be  maintained  by 
a  hot  blanket,  and  have  hot-water  bottles  placed  about  her  and 
be  kept  covered.  Common  sense  should  be  exercised  in  the 
use  of  these  measures,  not  because  the  patient  has  undergone 
an  operation,  but  because  they  are  needed.  I  have  seen  pa- 
tients on  the  hottest  days  in  summer  subjected  to  the  applica- 
tion of  hot-water  bottles  and  other  methods  of  maintaining 
heat,  when  heat  abstraction  was  indicated.  A  patient  with  a 
pulse  of  good  volume  and  bathed  with  perspiration  calls  for 
reduction  of  covering  and  withdrawal  of  artificial  heat  rather 
than  its  application.  When  heat  is  maintained  by  the  appli- 
cation of  hot-water  bags  and  bottles,  they  should  be  watched, 
that  the  restless  patient  does  not  displace  the  blanket  and  come 
in  contact  with  the  hot-water  receptacle.  Such  applications 
should  never  be  made  without  the  bag  or  vessel  having  been 
wrapped,  or  at  least  placed  external  to  a  blanket.     The  nurse 


30  CARE  01"  GYNECOLOGIC  PATIENTS 

should  know  just  where  each  one  of  them  is,  and  should  inves- 
tigate from  time  to  time  to  see  they  have  not  been  displaced. 
It  must  be  understood  that  the  resistance  of  a  patient  in  shock 
is  much  reduced,  so  that  she  would  be  burned  from  an  exposure 
that  otherwise  would  not  affect  her.  Should  a  burn  occur, 
the  nurse  should  not  attempt  to  conceal  it  from  the  physician, 
however  willing  the  patient  may  be  to  co-operate  in  the  decep- 
tion. Be  sure  it  will  come  to  his  knowledge  some  time,  and  he 
will  thereafter  fail  to  have  any  confidence  in  the  nurse.  The 
patient  in  bed,  the  room  should  be  darkened,  and  ventilation 
afforded  without  placing  her  in  a  draft.  The  members  of  the 
family  and  all  others  than  the  necessary  attendants  should  be 
requested  to  leave  the  room.  Even  when  the  patient  is  sleep- 
ing, with  pulse  and  breathing  good,  she  should  not  be  left  with- 
out skilled  attention,  for  without  warning  she  may  have  an 
attack  of  vomiting,  and  if  without  skilled  attention  may  by 
inspiration  draw  the  vomitus  into  the  trachea,  to  cause  a  sub- 
sequent attack  of  pneumonia.  The  nurse  keeps  a  record  sheet 
on  which  she  should  register,  in  severe  cases  at  least  every  four 
hours,  the  temperature,  pulse,  respiration,  and  any  s\TTiptonis 
which  may  have  a  practical  bearing  on  the  subsequent  course  of 
the  convalescence.  The  continuous  retention  of  one  position 
becomes  extremely  irksome  to  a  patient  who  has  been  unaccus- 
tomed to  lying  in  bed,  and  the  nurse  should  study  to  make  this 
imprisonment  as  endurable  as  possible.  Much  may  be  done 
for  her  comfort  and  distraction  by  frequently  changing  her 
position,  placing  a  pillow  beneath  the  limbs  or  under  a  shoul- 
der, turning  her  on  one  side,  and  placmg  the  limbs  semiflexed 


AFTER-CARE  3 1 

with  a  pillow  between  the  knees,  or  the  under  limb  extended 
while  the  upper  one  is  flexed  and  rests  on  a  pillow.  Bathing 
the  face,  shaking  up  the  pillow  beneath  the  head,  holding  her 
hand,  and  in  general  showing  that  the  nurse  has  sympathy  for 
her  charge  and  is  anxious  to  alleviate  her  discomfort,  has  a 
wonderful  effect  in  making  her  satisfied  with  the  situation. 
Never  let  the  patient  be  uncomfortable  when  her  distress  can 
be  obviated.  In  some  hospitals  there  seems  to  be  a  feeling  that 
the  patient  should  not  have  anything  under  her  head  for  some 
hours  after  the  operation,  but  this  is  like  many  other  miscon- 
ceptions. The  patient  may  at  once  have  a  pillow  unless  she 
has  lost  so  much  blood  as  to  render  it  desirable  to  keep  the  head 
low  in  order  that  the  blood  can  enter  it  without  increased  car- 
diac effort.  In  ordinary  cases  to  make  the  patient  go  without 
a  pillow  is  an  unnecessary  punishment.  The  patient  will  not 
infrequently  ask  for  water  and  more  often  for  broken  ice.  The 
latter  should  be  withheld,  for  its  administration  leads  to  dry- 
ness and  cracking  of  the  lips  and  tongue,  when  her  condition 
is  truly  uncomfortable.  It  is  better  that  the  patient  should  be 
given  hot  water  by  the  tablespoonful,  and  if  this  is  well-borne 
and  unattended  by  nausea  or  vomiting,  she  can  have  a  cup  of 
weak  tea,  quite  hot,  without  milk  and  with  but  little  sugar. 

The  nurse  not  only  watches  the  heart  action,  the  respira- 
tion, and  the  condition  of  the  skin,  but  later  the  performance  of 
other  functions,  as  evacuation  of  gas  by  bowel  and  the  desire 
to  pass  urine.  As  the  bowels  have  been  freely  evacuated,  the 
patient  has  taken  but  little  water  prior  to  the  operation,  and 
her  skin  has  possibly  acted  freely  during  and  after  it,  the  secre- 


32  CARE  OF  GYNECOLOGIC  PATIENTS 

tion  of  the  kidneys  will  necessarily  not  be  very  active,  and  the 
patient  may  not  express  any  desire  to  urinate  for  some  hours 
subsequently.  Ordinarily  this  need  occasion  no  anxiety  for 
the  first  twelve  or  fourteen  hours  unless  there  has  been  some 
operation  affecting  the  bladder,  making  it  undesirable  to  have 
the  latter  distended,  when  either  a  retention  catheter  will 
have  been  introduced  or  directions  given  that  the  patient  shall 
be  catheterized  at  frequent  intervals. 

CATHETERIZATION 

As  a  general  rule  the  employment  of  the  catheter  should  be 
avoided,  for  even  with  the  most  careful  aseptic  precautions  its 
frequent  use  irritates  the  mucosa  of  the  urethra,  causing  a 
urethral  hyperemia  or  subacute  cystitis,  and  the  neglect  to 
cleanse  the  parts  may  result  in  a  severe  urethritis  or  cystitis 
which  may  be  more  aggravating  than  the  condition  for  which 
the  operation  was  done.  The  patient  without  previous  train- 
ing in  the  use  of  the  bed-pan  may  find  it  difficult  to  pass 
urine  while  in  the  recumbent  position.  An  attempt  should 
be  made  b\'  the  nurse  to  awaken  the  desire  by  suggesting  the 
evacuation.  When  the  bed-pan  is  placed  it  should  be  warm 
and  have  some  hot  water  in  it,  as  the  heat  favors  the  evacua- 
tion. Running  water  from  a  faucet,  hot  water  allowed  to 
trickle  over  the  vulva,  or  poured  from  one  vessel  to  another,  or 
quite  hot  water  thrown  against  the  meatus  from  a  fountain- 
syringe  through  a  medicine-dropper  substituted  for  the  nozzle 
are  methods  which  ma\-  be  empk)yed  to  stimulate  the  flow. 
Occasionally  a  sensitive  patient  will  be  al)le  to  accompUsh  the 


CATHETERIZATION  33 

act  if  placed  on  the  pan  and  left  alone.  The  nurse  must  study 
her  patient  and  be  resourceful.  Should  the  patient  pass  no 
urine  within  eighteen  hours,  the  catheter  should  be  introduced 
even  though  there  is  no  discomfort.  The  instrument,  whether 
rubber  or  glass,  should  be  perfectly  clean,  and  where  its  use  is 
required  at  intervals  should  be  kept  in  a  bichlorid  solution  and 
rinsed  in  hot  water  before  its  use.  The  nurse  should  wash  and 
disinfect  her  hands.  The  vulva  should  be  carefully  washed  and 
the  labia  held  apart  during  the  introduction  of  the  instrument 
so  that  it  is  not  brought  in  contact  with  the  labia.  As  it 
enters,  the  external  end  of  the  instrument  is  kept  closed  with 
the  finger  so  that  its  introduction  will  not  allow  the  urine  to  be 
discharged  before  the  receptacle  is  at  hand.  When  the  bladder 
is  emptied,  the  finger  is  placed  over  the  catheter  end  as  it  is 
withdrawn  to  prevent  the  vulva  being  soiled  by  urine  retained 
in  it.  The  vulva  should  be  cleansed  after  the  completion  of 
the  procedure.  Where  the  introduction  of  the  catheter  shows 
that  no  urine  has  been  secreted,  the  action  of  the  kidneys  un- 
less contra-indicated  should  be  stimulated  by  the  administra- 
tion of  water  by  the  mouth,  the  Murphy  drip,  and  by  hypo- 
dermocleisis.  The  surgeon  or  the  intern  will  have  been  noti- 
fied and  these  measures  employed  at  his  suggestion.  Hot- 
water  bags  or  an  electric  pad  over  the  back  will  often  prove 
useful.  Digitalis,  caft'ein,  and  sodium  benzoate  may  be  ad- 
ministered internally.  Continued  suppression  may  indicate 
that  the  entrance  of  urine  into  the  bladder  is  blocked,  as  can 
readily  occur  in  some  operative  procedures.  I  had  the  mis- 
fortune to  tie  and  cut  both  ureters  in  the  removal  of  the 
3 


34  CARE  OK  GYNECOLOGIC  PATIENTS 

uterus  for  advanced  cancer.  The  complete  failure  to  secrete 
any  urine  for  two  days  demonstrated  to  me  that  it  was  neces- 
sary to  investigate  the  cause.  The  operation  had  been  done 
under  spinal  anesthesia,  and  repeating  it,  I  opened  the  abdomen 
to  find  both  ureters  neatly  tied.  I  released  and  transplanted 
them  into  the  bladder,  when  the  patient  recovered  and  died  a 
year  later  from  a  recurrence  of  the  disease.  I  saw  in  consul- 
tation two  patients,  one  of  whom  had  a  large  abdominal  cyst 
emptied  b}'  tapping,  which  proved  to  be  a  cyst  of  one  kidney. 
She  had  passed  no  urine  for  sixteen  days  when  I  was  called  to 
see  her,  and  with  my  approval  an  oj^ening  was  made  through 
the  back  into  the  remaining  kidney.  She  recovered  and  lived 
two  years,  when  she  died  after  a  second  tapping.  The  other 
patient  had  had  one  kidney  removed  and  passed  no  urine  sub- 
sequently until  after  she  had  the  remaining  kidney  opened. 
It  was  found  that  some  loose  tubercle  matter  from  the  renal 
pelvis  had  floated  into  and  blocked  the  orifice  of  the  ureter. 
This  patient  died  despite  the  drainage.  These  are  exceptional 
cases,  but  they  demonstrate  the  importance  of  being  alert  for 
the  recognition  of  adverse  conditions. 

NOURISHMENT 

While  it  has  l)ccn  demonstrated  that  acetonuria  is  a  con- 
sequence of  starvation,  yet  there  need  be  no  anxiety  about 
the  feeding  of  the  patient  in  the  first  twenty-four  hours  after 
operation.  In  the  majority  of  cases  the  disturbance  of  the 
secretions,  as  a  result  of  the  worry,  nervous  shock,  and  ad- 
ministration of  the  anesthesia,  is  so  great  that  food  if  taken 


NOURISHMENT  35 

would  be  unfitted  for  nutrition  and  be  a  source  of  irritation. 
The  patient  is  generall}^  satisfied  with  Hquids.  As  water  com- 
poses the  greater  part  of  the  tissues  of  the  body,  it  is  safe 
to  begin  with  a  tablespoonful  of  hot  water  every  half-hour  or 
hour,  and  if  this  is  well  borne,  cold  may  be  substituted.  If  ad- 
dicted to  tea,  a  cup  of  the  latter  may  be  given  hot  with  a 
small  quantity  of  sugar.  Albumen-water,  orange-juice,  or 
grape-juice  diluted  with  Vichy,  broths,  hot  or  cold  raisin  tea,  or 
cornmeal  gruel  may  be  given  durmg  the  first  twenty-four  hours. 
In  uncompUcated  cases  the  patient  may  have,  at  the  end  of 
this  time,  a  poached  egg  on  soft  toast  and  a  cup  of  coffee,  and 
gradually  assume  the  ordinary  diet.  The  inchnation  of  the 
patient  and  the  condition  of  the  digestive  tract  should  be 
carefully  studied  and  the  food  directed  accordingly.  The 
occurrence  of  nausea  and  vomiting  or  the  presence  of  t}Tn- 
panites  should  be  an  indication  for  withdrawing  food,  possibly 
lavage,  and  the  employment  of  saHne  or  glucose  solution  by  the 
rectum.  It  is  worse  than  useless  to  administer  food  to  a 
patient  who  is  constantly  vomiting,  or  whose  stomach  is  dis- 
tended with  gas,  or  into  which  the  contents  of  the  small  in- 
testine are  being  regurgitated.  The  absorptive  power  of  the 
stomach  is  sKght,  and  the  material  only  decomposes  and  adds 
to  the  toxemia  of  the  patient. 

While  the  nurse  understands  that  she  is  to  make  the 
patient  as  comfortable  as  conditions  will  permit,  she  should 
not  forget  that  she  is  on  guard  to  watch  for  danger  signals,  the 
occurrence  of  which  should  be  made  known  to  her  superiors, 
the  intern  and  surgeon  in  charge.     The  usual  sjTnptoms  which 


36  CARE  OF  GYNECOLOGIC  PATIENTS 

may  be  of  moment  in  the  order  of  their  occurrence  are  shock, 

nausea  and   vomiting,   hemorrhage   (external  and  internal), 

tympanites,  abdominal  pain  and  tenderness,  peritonitis,  and 

sepsis. 

SHOCK 

The  appearance  of  shock  is  favored  by  prolonged  opera- 
tion, the  exposure  of  the  contents  of  the  peritoneal  cavity  to 
evaporation  of  its  moisture  or  to  being  chilled,  to  the  ad- 
ministration often  of  an  unnecessary  amount  of  anesthetic,  to 
traction  on  the  viscera,  and  to  extensive  tearing  up  of  peritoneal 
structures.  The  susceptibility  to  shock  varies  in  different 
individuals.  One  may  be  shocked  without  any  apparent 
cause,  while  another  will  go  through  a  most  severe  opera- 
tion without  any  such  manifestation.  The  aim  in  treatment 
should  be  prophylactic.  The  bodily  heat  should  be  main- 
tained; the  amount  of  anesthetic  be  limited  to  the  lowest 
amount  compatible  with  the  performance  of  the  operation ;  the 
intestines  should  be  protected  from  chilling  and  evaporation; 
and,  where  the  operation  is  likely  to  be  prolonged  or  the  con- 
dition of  the  patient  enfeebled,  shock  should  be  anticipated  by 
the  cniplo)mcnt  of  continuous  h\-po(lcrmocl}'sis,  the  early 
administration  of  strychnin,  atropin,  or  ergone  hypodennically, 
and  if  necessary  the  intravenous  injection  of  a  solution  of 
sodium  chlorid  or  sodium  citrate.  These  procedures  may  be 
employed  during  or  following  the  operation,  according  to  the 
exigencies  of  the  case,  and  subsequently  demand  a  careful  and 
competent  anesthetist  who  can  give  warning  of  danger,  the 
need  of  stimulation,  and  the  character  and  quantity  required. 


SHOCK  37 

Shock  is  indicated  by  increased  frequency  and  diminished 
volume  of  the  pulse,  the  latter  frequently  being  imperceptible 
at  the  radius.  The  face  and  lips  become  pale  and  bloodless, 
the  skin  is  covered  with  a  perspiration  which  from  the  evapora- 
tion and  diminished  heat  formation  causes  the  surface  to  be 
cold  and  clammy.  The  pupils  are  dilated,  and  if  the  patient 
is  conscious  complains  of  faintness,  of  inabihty  to  see,  and  is 
quite  restless,  rolling  her  head  from  side  to  side.  The  occur- 
rence of  nausea  preceding  an  attack  of  vomiting  will  not  in- 
frequently cause  the  pulse  to  become  feeble  and  for  a  time  even 
imperceptible,  but  it  comes  on  rather  suddenly  and  is  not 
accompanied  by  the  other  symptoms  mentioned.  Shock  oc- 
curs during  an  operation  or  immediately  following  it,  and 
under  rest,  stimulation,  promotion  of  bodily  heat,"  the  patient 
recovers.  The  baneful  effects  of  shock  may  be  obviated  and 
overcome  by  the  position  of  the  patient — elevating  the  foot  of 
the  bed  so  that  the  blood  shall  have  easy  access  to  the  brain 
without  undue  heart  action.  In  profound  shock  the  extremi- 
ties should  be  bandaged  as  far  as  the  trunk,  so  that  the  quan- 
tity of  blood  for  the  vital  centers— the  brain,  heart,  and  lungs 
—should  be  greater  while  the  tissues  can  wait.  INIeasures 
to  combat  shock  should  be  instituted  promptly.  As  water 
composes  the  greater  portion  of  the  body,  it  should  be  intro- 
duced promptly  and  its  quantity  effectively  maintained. 
This  may  be  accomplished  by  continuous  rectal  instillation, 
hypodermoclysis,  or  intravenous  injection.  The  bodily  heat 
must  be  maintained  by  artificial  measures,  as  hot  blankets, 
hot-water  bags  or  bottles,  or  electric  pads.     WTiere  hot  water 


38  CARE  OF  GYNECOLOGIC  PATIENTS 

is  employed,  care  should  be  exercised  that  the  receptacles  are 
accurately  stoppered,  that  they  are  securely  wrapped,  and 
brought  directly  in  contact  with  the  skin  surface.  Marked 
restlessness  and  continued  uneasiness  of  a  patient  who  is 
semiconscious  should  be  an  indication  for  investigating  care- 
fully the  condition  of  the  receptacles,  for  a  severe  burn  is 
easily  made  under  such  circumstances,  and  the  injury  always 
seems  an  unforgivable  offense  to  the  patient  and  her  friends. 
The  successful  treatment  of  shock  often  demands  the  best 
therapeutic  judgment  to  assure  that  the  right  drug  and  in 
proper  quantity  is  given.  Vital  forces  are  enfeebled  and  sleep- 
ing nerve  action  must  be  awakened.  Depressing  measures 
must  be  discontinued,  as  it  is  better  that  the  patient  feel  some 
pain  than  that  the  anesthetic  should  be  maintained.  If  ether 
or  chloroform  has  been  given,  oxygen  should  be  substituted; 
sweating  and  leakage  of  the  skin  should  be  obviated  by  the 
administration  of  atropin,  j^j^  to  ywo  grain;  flagging  of  the 
pulse,  a  ])inched  expression  of  the  face  should  be  combated 
by  strychnin  sulphate,  r^jf  to  -^2  grain  hypodermically.  Hypo- 
dermoclysis  of  a  i  per  cent,  sodium  chlorid  or  sodium  citrate 
solution  at  a  temperature  of  105°  V.  into  the  loose  tissue  be- 
neath the  breasts,  in  the  axillary  spaces,  or  in  the  buttocks  is 
valuable.  The  utmost  asepsis  must  be  employed  in  its  ad- 
ministration, for  the  introduction  of  infection  but  adds  to  the 
danger.  When  the  pulsation  in  the  extremities  fails,  the  blood- 
pressure  is  subnormal,  the  puj)ils  are  dilating,  no  time  should 
be  lost  in  the  intravenous  administration  of  a  saline  solution. 
Instruments. — See  Fig.  8. 


SHOCK 


39 


The  arm  of  the  patient  from  the  hand  to  the  axilla  should 
be  washed  with  gasoline  and  then  painted  with  a  3I  per  cent. 


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solution  of  iodin.     A  rubber  tube  is  placed  around  the  upper 
arm  to  control  the  return  of  blood  by  the  veins,  and  the  median 


40  CARE  OF  GYNECOLOGIC  PATIENTS 

basilic  or  cephalic  vein,  according  to  its  size,  should  be  exposed 
by  an  incision.  The  vein  is  separated  from  its  fascia,  a  grooved 
director  passed  beneath  it,  a  ligature  tied  on  the  distal  end,  the 
rubber  tube  about  the  arm  removed,  a  second  ligature  thrown 
about  the  proximal  side  of  the  vessel,  the  front  of  the  vein 
picked  up  with  forceps  and  a  transverse  cut  made  into  it 
through  which  the  canula  is  connected  with  the  receptacle,  and 
with  the  solution  at  the  temperature  of  102°  F.  running,  is  intro- 
duced, and  ligature  previously  placed  about  it,  tied  with  one 
turn  of  the  ligature.  The  fluid,  a  i  per  cent,  salt  solution  to 
which  may  be  added  adrenalin  chlorid  solution,  i  fluidram  (i: 
1000),  or  caffein  citrate,  4  grains,  is  allowed  to  run  into  the  vein 
slowly,  taking  care  that  the  heart  shall  not  be  flooded,  until  a 
quart  of  the  solution  has  been  introduced.  The  canula  should 
be  withdrawn  by  the  intern,  while  the  surgeon  ties  the  knot  to 
prevent  any  bleeding  and  closes  the  wound  with  sutures.  It  is 
just  as  well  before  closing  to  cut  the  vein  across  between  the 
sutures,  as  it  removes  unpleasant  traction,  and  with  ligatures 
on  the  vessel  the  intermediate  portion  is  of  no  value.  The 
wound  should  be  washed  with  alcohol,  dried  with  sterile 
gauze,  brushed  with  an  iodin  solution,  and  a  dressing  of  sterile 
gauze  applied,  secured  by  a  sterile  bandage. 

Hypodermoclysis. — The  injection  of  salt  solution  beneath 
the  skin  is  practised  to  sustain  the  strength  of  the  patient, 
prevent  shock,  and  promote  elimination.  As  has  been  men- 
tioned, it  is  often  employed  where  the  condition  of  the  patient 
is  bad  and  an  operation  is  likely  to  be  prolonged.  The  sur- 
geon should  be  provided  with  a  graduate  glass  with  a  nipple 


NAUSEA  AND   VOMITING  41 

opening  at  the  bottom  to  which  a  tube  can  be  attached,  and 
through  a  needle  at  the  tube  end  plunged  into  the  loose  cellu- 
lar tissue  the  fluid  can  be  transmitted.  It  is  better  to  have  a 
Y  in  the  tube  to  which  two  tubes  with  needles  afiixed  can  be 
secured,  and  thus  the  fluid  introduced  under  both  breasts  or 
into  both  axilLne  at  the  same  time.  During  an  operation  the 
amount  of  the  flow  and  quantity  to  be  introduced  can  be  under 
the  direction  of  the  anesthetist.  The  apparatus  and  the  fluid 
employed  as  well  as  the  skin  through  which  the  punctures  are 
made  should  ah  be  aseptic.  Failure  to  exercise  these  precau- 
tions will  be  hkely  to  result  in  infection  and  suppuration. 

The  intravenous  injection,  or  repeated  hypodermoclysis, 
may  be  followed  and  supplemented  if  demanded  by  the  con- 
tinuous Murphy  drip.  The  patient  must  be  kept  quiet.  The 
administration  of  morphin  in  small  doses,  y6  to  yV  grain,  at 
intervals  of  three  to  four  hours  will  act  as  a  stimulant  and 
relieve  the  nerve  irritation. 

NAUSEA  AND   VOMITING 

Nausea  is  very  common  after  abdominal  operations, 
whether  with  general  or  local  anesthesia.  The  reflex  effect 
of  opening  the  abdomen  and  disturbing  the  viscera  will  not 
infrequently  cause  nausea  and  vomiting,  even  when  the 
anesthesia  is  secured  by  spinal  injections.  It  is  much  more 
constant  and  prolonged  when  a  general  anesthetic,  as  ether  or 
chloroform,  is  given.  Nausea  and  vomiting  after  the  ad- 
ministration of  ether  is  generally  to  be  expected,  and  its  con- 
tinuance may  be  shortened  by  allowing  the  patient  to  take  a 


42  CARE  OF  GYNECOLOGIC  PATIENTS 

good  draft  of  warm  water  or  precede  the  water  by  a  solution 
of  sodium  bicarbonate,  |  to  i  dram,  in  one-half  glass  of  hot 
water.  The  patient  vomits  with  greater  ease  when  she  has 
something  in  the  stomach,  and  the  act  washes  off  the  irritating 
mucus  and  promotes  the  elimination  of  ether.  When  there 
is  reversed  peristalsis,  and  the  bile  and  contents  of  the  duode- 
num arc  being  regurgitated  into  the  stomach,  a  Seidlitz  powder 
may  be  given,  dissolving  the  sodium  bicarbonate  in  one-half 
a  glass  of  water  and  dropping  the  tartaric  acid  dry  on  it,  and 
if  given  while  effervescing  will  often  speedily  cjuiet  the  nausea. 
It  distends  the  stomach  and  a  part  of  it  passes  through  the 
pylorus.  If  it  is  vomited,  it  washes  out  the  stomach,  neutral- 
izes the  secretion,  and  leaves  the  patient  more  quiet  following 
its  use;  if  it  is  not  vomited,  it  passes  into  the  intestines  and 
causes  peristalsis  to  become  normal  and  carries  the  vitiated 
secretions  down.  The  accomplishment  of  an  evacuation, 
whether  gas  or  fecal,  frequently  relieves  the  patient  from  fur- 
ther discomfort.  The  continuation  of  nausea  and  vomiting 
after  the  first  twenty-four  hours  should  be  regarded  as  a 
symptom  demanding  consideration,  as  it  is  frequently  a  pre- 
monitory indication  of  peritonitis  and  will  be  discussed  when 
that  complication  is  considered. 

HEMORRHAGE,    EXTERNAL   AND   INTERNAL 

Bleeding  from  the  uterus  or  vagina  is  recognized  by  the 
appearance  of  blood  at  the  vulva  and  may  demand  careful 
attention.  Severe  hemorrhage  may  follow  failure  to  secure 
the  vessels  of  the  cervix  and  vagina  and  should  demand  instant 


HEMORRHAGE,  EXTERNAL  AND  INTERNAL  43 

measures  for  its  control.  The  bleeding  may  be  overcome 
by  the  introduction  of  gauze  packing  and  the  employment  of 
a  pad  secured  by  a  bandage  externally.  The  elevation  of  the 
foot  of  the  bed,  making  the  supply  to  the  bleeding  vessels  more 
difficult,  will  often  be  effective,  but  severe  hemorrhage  should 
demand  ligation.  I  have  seen  extensive  pelvic  hematoma 
formed  by  dissection  back  of  the  blood  where  efforts  at  its 
control  by  tampons  have  been  essayed. 

Internal  hemorrhage  is  generally  a  result  of  faulty  appli- 
cation of  ligatures  to  vessels  during  an  abdominal  operation. 
The  ligation  of  a  short  thick  stump  may  be  followed  by  its 
shrinking  to  such  an  extent  as  to  permit  a  vessel  to  retract  and 
hemorrhage  occur  in  the  stump  until  the  effect  of  the  ligature 
is  overcome,  the  tissue  slips  out  of  its  control,  and  bleeding 
occurs  unrestrained  into  the  peritoneal  cavity.  That  such  a 
hemorrhage  is  progressing  would  be  mdicated  by  the  appear- 
ance of  a  gradually  weakening  pulse  in  a  patient  who  has  been 
put  to  bed  after  an  operation  with  a  pulse  of  good  volume  and 
otherwise  in  good  condition.  The  breathing  will  be  sighing, 
the  patient  restless,  rolling  her  head  from  side  to  side,  com- 
plaining of  failing  vision,  with  delirium,  dilated  pupils,  the 
skin  covered  with  cold,  clammy  perspiration,  the  lips  pale,  and 
the  extremities  becoming  cold,  while  the  pulse  has  possibly  dis- 
appeared from  the  wrist.  These  are  the  symptoms  of  shock,  but 
the  latter  does  not  appear  at  such  a  time  unless  for  cause,  and 
in  the  great  majority  of  cases  the  cause  is  internal  hemorrhage. 
Such  symptoms  occur  in  cases  which  have  not  undergone 
operation,  but  in  such  is  due  also  to  internal  hemorrhage,  and 


44  CARE  OF  GYNECOLOGIC  PATIENTS 

in  the  majority  of  women  suffering  from  such  symptoms  the 
condition  should  be  attributed  to  a  complication  of  the  course 
of  an  ectopic  gestation  sac  or  termination  of  an  abnormal  preg- 
nancy by  tubal  abortion.  The  occurrence  of  such  symptoms 
should  lead  the  nurse  to  call  for  the  aid  of  the  intern  or  surgeon. 
While  waiting,  she  should  remove  the  pillow  from  beneath  her 
head,  prepare  for  the  administration  of  salt  solution  per  rec- 
tum, by  hypodermoclysis,  and  by  intravenous  injection. 
The  operating  room  should  be  prepared  so  that  not  a  minute 
of  time  shall  be  lost  when  the  attendant  is  secured.  Stimu- 
lants should  not  be  given,  however,  .unless  the  operator  is  ready 
to  reopen  the  wound.  Any  promotion  of  the  activity  of  the 
circulation  would  endanger  the  driving  out  of  a  clot  which  has 
formed  in  the  vessel  when  the  circulation  is  enfeebled,  and 
the  only  hope  for  the  recovery  of  the  patient,  outside  of  liga- 
tion, is  that  the  clot  may  so  fimily  plug  the  vessel  that  the 
regained  force  shall  not  drive  it  out  and  reproduce  the  bleed- 
ing. The  desperate  condition  of  a  living  patient  should  not 
deter  the  surgeon  from  resort  to  measures  to  secure  the  vessel 
and  thus  afford  her  chance  for  life. 

Some  two  years  ago,  when  operating  before  a  section  of 
students  at  Jefferson,  a  nurse  came  to  the  intern  assisting  me 
and  said  something  which  I  did  not  catch  about  a  patient  who 
had  been  admitted.  He  gave  directions  to  call  another  intern. 
Soon  she  came  back,  and  I  then  told  him  to  go,  that  I  would 
complete  the  operation  with  the  aid  of  the  student  assistant. 
When  I  went  into  the  ward,  after  I  had  completed  the  opera- 
tion, I  found  him  practising  artificial  respiration  on  a  patient 


TYMPANITES  45 

who  seemed  to  be  dead.  He  suspended  it  with  the  remark,  "It 
is  too  late."  I  could  not  distinguish  the  pulse  at  the  wrist,  nor 
could  I  hear  the  heart  beat,  but  imagined  that  I  noticed  a 
movement  as  if  an  effort  at  respiration.  I  introduced  the 
tube  of  an  oxygen  tank  into  her  nostril  and  directed  that  the 
intern  should  open  a  vein  and  begin  an  intravenous  injection. 
Soon  there  was  a  distinct  gasp,  and  we  continued  the  measures, 
having  preparations  made  to  open  the  abdomen.  She  was 
wheeled  into  the  operating  room,  and  after  hasty  preparation 
the  abdomen  opened.  A  ruptured  tube  was  picked  up,  H- 
gated  below  the  gestation  sac,  and  removed,  the  blood  hastily 
scooped  out  from  the  cavity,  and  the  wound  closed.  The  m- 
travenous  injection  was  continued  during  the  operation,  and 
at  its  end  the  patient  was  breathing  normally  and  had  a  pulse 
of  good  volume.  Barring  a  slight  phlebitis,  she  recovered 
without  difficulty  and  left  the  hospital  at  the  end  of  a  month  in 
fair  condition.  This  case  has  been  recounted  to  impress  the 
importance  of  not  giving  up  a  patient  as  hopeless  so  long  as 
life  can  be  recognized.  It  cannot  be  too  strongly  impressed  on 
all  parties  in  charge  of  such  a  patient  that  stimulants  can  only 
be  used  with  safety  when  it  is  certain  that  the  bleeding  vessel  is 
secured.  Any  additional  force  to  the  circulation  prior  to  this 
but  endangers  the  patient  through  driving  out  the  clot. 

TYMPANITES 

The  distention  of  the  alimentary  canal  by  gas  is  an  indi- 
cation of  peritonitis  or  decomposition  of  the  intestinal  con- 
tents with  the  formation  of  gas  and  toxins.     It  ma}'  occur 


46  CARE  OF  GYNFXOLOGIC  PATIENTS 

either  in  the  upper  or  lower  portion  of  the  tract,  or  the  entire 
canal  may  seem  to  be  affected,  when  the  abdomen  is  greatl}  dis- 
tended. It  is  generally  accompanied  by  reversed  peristalsis 
and  regurgitant  vomiting.  The  vomitus  is  likely  to  be  a  dark- 
brown  material,  extremely  offensive,  and  sometimes  such  as 
to  lead  the  observer  to  believe  it  fecal.  The  pressure  of  the 
distention  against  the  diaphragm  interferes  with  the  action  of 
the  heart  and  lessens  the  abiUty  of  the  patient  to  breathe  deeply, 
so  that  oxygenation  is  greatly  obstructed.  The  countenance 
presents  evidence  of  toxemia,  and  the  patient,  unless  timely 
relief  is  secured,  will  surely  succumb.  The  administration  of 
nourishment  b'ut  adds  to  the  distress  and  danger.  It  only  in- 
creases the  material  to  be  infected  and  undergo  decomposition, 
adding  to  the  distention  and  toxemia.  The  distention  may  be 
attacked  from  below  or  above,  according  to  its  situation,  or 
relief  may  be  afforded  by  securing  evacuation  from  both  ends 
of  the  canal;  by  the  rectal  tube,  or  enema  from  below,  and  the 
use  of  the  stomach-tube  or  lavage  from  above.  In  all  cases 
where  the  patient  is  so  distended,  and  is  constantly  spitting  up 
mouthfuls  of  offensive  material,  nothing  affords  such  quick 
relief  and  changes  the  appearance  of  the  patient  as  the  intro- 
duction of  the  stomach-tube.  Its  entrance  into  the  stomach 
will  often  be  followed  by  the  forcible  discharge  of  gas  and  a  large 
quantity  of  foul-smelling  material.  The  nurse  should  have 
ready  2  or  3  gallons  of  water  at  a  temperature  of  105°  F.  in 
which  has  been  dissolved  sodium  bicarbonate,  forming  a  2 
per  cent.,  or  sodium  chlorid  (i  per  cent.)  solution,  and  after 
the  tube  anointed  with  glycerin  has  been  passed  into  the 


TYMPANITES  47 

stomach,  the  patient  encouraged  not  to  resist,  and  the  contents 
of  the  stomach  have  been  syphoned  off,  then  the  solution  is 
poured  in  until  the  stomach  is  well  distended,  when  it  is  again 
syphoned  out,  and  repeated  until  the  water  returns  clear. 
As  these  symptoms  generally  indicate  peritonitis,  it  is  better 
that  the  removal  of  the  tube  shall  be  followed  by  the  admin- 
istration of  morphin  hypodermicalh',  beginning  with  I  to  \ 
grain,  and  the  patient  be  subsequently  kept  moderately  under 
the  drug  in  doses  of  I  to  yV  grain  every  three  hours.  Nothing, 
not  even  water,  should  be  allowed  to  enter  the  stomach.  The 
patient  will  be  thirsty,  and  should  be  allowed  to  rmse  her 
mouth  with  water  flavored  with  lemon-juice.  Wetting  the 
lips  with  glycerin  and  rosewater  will  allay  the  dryness  and 
thirst.  The  tissues  should  be  suppHed  with  the  necessary 
water  by  the  Murphy  drip  into  the  rectum  and  by  hypodermo- 
clysis.  A  pint  of  sodium  chlorid  or  sodium  citrate  (i  per  cent, 
solution)  may  be  introduced  beneath  each  breast  twice  in  the 
twenty-four  hours.  When  the  distention  affects  the  lower 
part  of  the  abdomen,  enemas  frequently  afford  the  necessary 
relief.  An  enema  of  soapsuds  alone,  or  combined  with  tur- 
pentine or  asafetida,  will  often  cause  a  free  discharge  of  gas 
and  complete  relief.  An  enema  containing  an  ounce  each  of 
magnesium  sulphate,  water,  and  glycerin,  hence  called  a 
triplex  enema,  will  often  be  efficient.  I  have  learned  by  ex- 
perience to  rely  upon  i  ounce  of  alum  dissolved  in  i  quart  of 
water  at  a  temperature  of  105°  F.,  slowly  injected  with  a 
gravity  syringe,  as  an  effective  stimulant  of  peristalsis.  Usu- 
ally the  passage  of  gas  brings  about  the  desired  effect  and  the 


48  CARE  OF  GYNECOLOGIC  PATIENTS 

patient  is  subsequently  comfortable.  ]\Iany  surgeons  place 
great  reliance  on  eserin  salicylate,  x^Vto  ^^q-  grain,  every  hour  for 
three  or  four  doses  or  until  gas  escapes  per  rectum,  but  it  has 
always  seemed  to  me  inconsiderate  to  apply  the  whip  when 
uncertain  as  to  the  character  of  the  obstruction,  and  from 
personal  experience,  after  a  recent  operation  which  was  fol- 
lowed by  tympanites,  I  should  hesitate  still  more  before  re- 
sorting to  it.  I  was  uncomfortably  distended,  and  after  the 
second  injection  of  eserin  there  was  a  large  discharge  of  gas, 
but  with  it  a  state  of  collapse  attended  with  profuse  perspira- 
tion, in  which  I  felt  myself  nearer  death  than  I  had  ever  pre- 
viously experienced.  Instances  have  been  recorded  where 
such  injections  have  stimulated  so  violent  peristalsis  that  in 
the  face  of  obstruction  the  intestine  has  been  torn  and  death 
resulted. 

ABDOMINAL   PAIN   AND    TENDERNESS 

I'ain  and  tenderness  are  natural  consequences  of  every  ab- 
dominal operation.  They  vary  in  degree  in  different  persons 
and  according  to  the  character  of  the  operation  and  the  sub- 
sequent reaction.  An  ordinary  uncomplicated  case  of  a  pa- 
tient sane  and  well  balanced  may  go  through  convalescence  with 
apparentl}'  slight  distress.  The  amount  of  pain  will  depend 
to  some  degree  uj^on  the  character  of  closure  of  the  wound. 
Under  the  old  method  of  through-and-through  suture  the 
traction  of  the  sutures  on  the  skin  was  provocative  of  severe 
pain  until  their  removal.  But  where  the  wound  is  closed  with 
sutures  in  layers  the  traction  on  the  skin  is  slight,  and  unless 
infection   has   occurred    the   distress   is   not  great.     Marked 


u    j^i- 


PAC 


PERITONITIS  49 

pain  and  tenderness  in  such  cases  is  indicative  of  some  com- 
plication, as  infection  in  the  wound  or  within  the  peritoneal 
cavity,  and  in  the  latter  may  be  caused  by  peritonitis.  The 
patient  should  be  encouraged  to  bear  the  discomfort  of  the 
operation  without  resort  to  anodynes,  and  the  latter  resorted 
to  only  for  the  rehef  of  restlessness  which  proves  more  dis- 
tressing than  would  the  drug  by  which  it  may  be  overcome. 

PERITONITIS 

A  limited  amount  of  peritoneal  inflammation  is  a  conse- 
quence of  every  abdominal  operation  and  is  necessary  to  the 
reparative  process.  The  aim  of  the  management  must  be  to 
so  conduct  the  treatment  of  the  patient  that  this  inflammatory 
process  shall  not  transcend  the  benevolent  status  and  become 
dangerous.  The  technic  of  the  operation  has  been  conducted 
with  the  purpose  of  limiting  the  introduction  of  infection  and 
thus  avoiding  grave  inflammation.  The  source  of  the  infec- 
tion may  be  faulty  technic,  permitting  its  introduction  from 
without,  or  the  extent  of  the  peritoneal  injury  may  be  so 
extensive  that  the  resulting  adhesions  wiU  cause  stasis  and  the 
transudation  through  the  intestinal  wall  of  microorganisms 
which  result  in  development  of  extensive  inflammation. 
Severe  loss  of  blood,  prolonged  operation,  profound  anesthesia, 
intestinal  stasis  are  all  causes  of  diminished  resistance  which 
greatly  favor  the  development  of  peritonitis.  The  presence 
of  peritonitis  is  indicated  by  increased  abdominal  pain  and 
tenderness,  nausea  and  vomiting  continuing  or  coming  on 
after  the  flrst  twenty-four  hours  subsequent  to  operation,  rapid 

4 


50  CARE  OF  GYNECOLOGIC  PATIENTS 

breathing  and  frequent  pulse,  with  an  anxious  appearance  of 
the  face  which  soon  becomes  pinched  and  worn.  The  abdomen 
is  distended  either  in  the  lower  or  upper  part,  or  both,  accord- 
ing to  the  seat  and  severity  of  the  attack.  The  patient  lies 
on  her  back  with  the  limbs  drawn  up  and  dreads  any  move- 
ment. The  abdominal  distention  soon  leads  to  a  toxemia 
from  the  shallow  breathing  and  consequent  insufticient  oxy- 
genation, and  from  the  absorption  of  the  toxic  products  formed 
in  the  intestinal  tract.  Such  a  patient  will  be  consequently 
vomiting  small  quantities  of  dark-colored,  foul-smelling  ma- 
terial, which  afTords  no  opportunity  for  rest  and  yet  without 
relief  of  the  distention.  It  is  futile  to  attempt  nourishment 
of  such  a  patient,  for  anything-  introduced  into  the  stomach 
is  at  once  infected  and  rendered  unfit  for  nutrition  if  the  diges- 
tive forces  were  not  entirely  suspended  by  the  infective  proc- 
ess. The  contractile  power  of  the  intestine  is  soon  lost  and 
the  nutrition  of  the  patient  rapidly  becomes  precarious.  The 
early  practitioners  treated  these  cases  by  splinting  the  intes- 
tines by  the  administration  of  opium  or  its  derivatives;  later, 
the  plan  was  to  administer  saline  purgatives  and  thus  make  the 
intestine,  as  Tait  suggested,  through  free  watery  evacuations, 
serve  as  a  drainage-tube  for  the  peritoneal  cavit\'.  When  the 
intestine  was  blocked  by  a  twist,  or  through  a  paralysis  from 
distention,  the  treatment  was  ineffective,  resulting  only  in 
reversed  peristalsis,  obstinate  vomiting,  and  rapid  loss  of 
strength.  Ochsner  pointed  out  that  in  cases  of  peritonitis  the 
most  effective  treatment  was  to  eni])ty  the  tract  by  enemas 
and  lavage  and  secure  rest  by  the  use  of  morphin  hypoder- 


PERITONITIS  51 

mically,  giving  neither  medication  nor  food  by  the  mouth, 
and  supplying  the  much-needed  water  for  the  system  by  the 
continuous  instillation  of  salt  solution,  known  as  the  Murphy 
drip.  The  ethcacy  of  this  treatment  with  drainage  was  still 
further  facihtated  by  placing  the  patient  in  a  half-sitting 
(Fowler's)  position,  especially  when  a  vaginal  incision  and  a 
vaginal  drain  had  been  instituted.  The  rest  and  deprivation 
will  often  estabhsh  resolution  and  ensure  recovery.  Where 
there  is  evident  suppuration,  and  the  patient  the  victim  of 
suppurative  peritonitis,  a  vaginal  incision,  indeed,  other  in- 
cisions in  the  most  dependent  portions  of  the  abdomen  as  well, 
the  insertion  of  a  split  rubber  drain  sutured  in  place,  the  em- 
ployment of  the  Fowler  position,  and  the  continuous  Murphy 
drip  will  promote  the  thorough  irrigation  of  the  peritoneal 
ca^^ty ,  and  often  mean  the  difference  between  recovery  and  dis- 
solution. Too  great  anxiety  should  not  be  exercised  as  to 
evacuation  of  the  bowels  or  resort  to  nourishment  through  the 
stomach.  Mental  and  physical  rest,  through  the  employment 
of  morphin,  the  maintenance  of  the  support  by  the  salt  solu- 
tion drip,  and  the  promotion  of  drainage  by  position  and  vents, 
should  be  regarded  as  the  proper  method  of  treatment.  The 
introduction  of  food  through  the  stomach  should  be  under- 
taken with  the  greatest  care  and  in  small  quantities  until  it 
has  been  demonstrated  that  the  material  can  be  safely  disposed 
of.  Not  infrequently  the  improvement  will  be  indicated  by 
the  discharge  of  a  large  quantity  of  gas  and  fecal  matter  per 
rectum  and  the  gradual  subsidence  of  the  abdominal  disten- 
tion.    Vomiting  no  longer  occurs  and  suitable  food  is  assim- 


52  CARE  OF  GYNECOLOGIC  PATIENTS 

ilatcd  when  administered  by  the  stomach.  Occasionally  the 
salt  solution  per  rectum  is  not  retained.  Under  such  circum- 
stances the  instillation  should  be  suspended,  a  larger  dose  of 
morphin  given  hypodcrmically,  and  after  it  has  quieted  the 
irritation  the  flow  can  be  renewed,  or  it  may  be  given  for  a 
series  of  three  hours  and  the  patient  be  allowed  to  rest  an  equal 
period.  Patients  may  be  able  to  take  it  thus  intemiittently, 
when  they  would  not  retain  it  without  the  period  of  rest.  If 
the  condition  of  the  patient  demands,  the  solution  may  be 
administered  by  hypodermoclysis,  a  pint  of  the  solution 
beneath  each  breast,  or  into  the  loose  tissues  of  the  axilla  or 
buttocks,  twice  in  the  twenty-four  hours.  In  the  employ- 
ment of  the  dri})  or  hypodermoclysis,  when  a  drain  does  not 
exist  the  excretion  of  the  urine  should  be  watched  to  make 
sure  that  the  balance  between  imbibition  and  excretion  is 
maintained,  for  I  have  seen  patients  become  quite  dropsical 
when  excretion  was  deficient.  The  result  in  peritonitis  will 
depend  upon  the  virulence  of  the  infection  and  the  resistance  of 
the  patient.  Naturally,  the  prompt  and  jutlicious  treatment 
of  the  case  will  effectually  promote  the  resistance. 

SEPSIS 

Like  peritonitis,  this  condition  is  an  indication  of  the 
spread  of  infection.  It  may  be  local,  as  in  the  wound,  or  be- 
come general,  when  it  is  known  as  systemic,  and  may  have 
no  palpable  localization.  It  is  against  this  general  distribu- 
tion that  all  our  efforts  at  asepsis  are  directed.  In  spite  of  all 
our  precautions,  some  infectious  microorganisms  do  come  in  con- 


SEPSIS  53 

tact  with  every  wound,  and  our  study  is  to  so  do  the  work  that 
no  favorable  soil  is  afforded  for  their  cultivation  and  develop- 
ment; not  only  that  a  favorable  soil  may  not  be  afforded,  but 
that  the  powers  of  resistance  of  the  patient  may  be  maintained 
so  unimpaired  that  she  will  be  able  to  withstand  the  onslaught 
of  microorganisms  present.  Accurate  diagnosis;  well-calcu- 
lated operative  procedures;  thorough  preparation;  carefully 
instructed  assistants  who  are  prepared  for  every  move  of  the 
surgeon  so  that  nothing  shall  be  left  to  chance ;  the  administra- 
tion of  anesthesia  adapted  to  the  exigencies  of  the  particular 
case,  and  in  quantity  only  sufficient  to  meet  the  necessary 
requirements;  rapid,  skilful,  yet  well-directed  operation  are 
all  factors  in  favoring  resistance  and  ensuring  against  sepsis. 
Prolonged  operation,  deep  anesthesia,  and  exposure  of  the 
intestines  to  cold  and  prolonged  evaporation  are  prolific  causes 
for  the  development  of  septic  infection.  The  presence  of  sep- 
sis is  manifested  by  rise  of  temperature,  quickened  pulse,  loss 
of  appetite,  and  a  sense  of  anxiety  and  discomfort.  The  tem- 
perature gradually  rises  and  the  variation  may  be  marked 
between  morning  and  evening.  The  temptation  is  great  to 
combat  this  rise  by  the  administration  of  some  antifebrile 
agent,  as  one  of  the  coal-tar  preparations,  but  such  a  course  is 
a  mistake,  for  the  rise  in  temperature  is  not  only  an  indication 
of  the  development  of  the  infection,  but  also  a  gage  of  the  re- 
sistance of  the  individual  forces  to  the  invasion,  and  should  not 
be  handicapped.  A  careful  investigation  should  be  instituted 
for  points  of  localization,  so  that  the  operator  may  be  ready  to 
assist  by  the  drainage  of  pockets  through  which  the  infection 


54  CARE  OF  GYNECOLOGIC  PATIENTS 

is  being  developed  and  disseminated.  The  abdominal  wound 
should  be  inspected,  and  if  very  tender  or  swollen,  or  if  it 
presents  indication  of  a  collection  of  blood  or  serum,  a  vent 
should  be  afforded.  The  possibility  of  such  an  occurrence  is 
one  of  the  arguments  against  the  continuous  suture  for  closing, 
as  when  a  wound  has  to  be  reopened  or  a  vent  secured  for  drain- 
age the  cutting  of  a  suture  weakens  the  entire  wound  and  en- 
dangers its  opening.  This  danger,  however,  can  be  obviated 
by  making  an  incision  at  the  side  of  the  wound  and  thus  avoid 
cutting  the  sutures.  Such  trap  drains  afford  escape  for  the 
pent-up  collection  and  ensure  rapid  recovery  of  the  wound  with 
the  least  possible  danger  of  subsequent  weakness.  The  re- 
covery is  favored  by  keeping  the  wound  covered  by  a  moist 
dressing,  preferably  several  thicknesses  of  gauze  wet  with  a 
2  per  cent,  sodium  bicarbonate  solution,  covered  with  paralhn 
paper,  and  over  this  a  hot- water  bottle.  This  procedure  pro- 
motes liquefaction  of  clots  in  hematoma  and  the  separation  of 
sloughs  when  the  condition  is  a  plain  infection  of  the  wound. 
The  development  of  infection  prevents  disintegration  and 
absorption  of  the  catgut  sutures,  and  they  usually  have  to  be 
pulled  out  before  the  wound  will  heal.  In  tubercular  wounds 
the  sinuses  which  form  between  the  layers  sometimes  become 
lined  with  an  adventitious  membrane  and  refuse  to  heal  until 
the  wound  above  is  split  open  and  the  tract  cureted  and 
cauterized  with  carbolic  acid  or  iodiii  and  resutured.  The 
time  spent  in  cleansing  and  cauterizing  such  sinuses  is  generally 
time  lost,  and  the  cure  of  the  condition  is  best  ensured  by 
immediate  opening  and  closure  of  the  wound.     Where  the 


SEPSIS  55 

examination  of  the  wound  fails  to  disclose  any  localization,  a 
vaginal  examination  should  be  made.  Not  infrequently 
there  will  be  some  thickening  between  the  uterus  and  rectum 
or  about  the  uterus  to  indicate  local  exudate  and  infection. 
Here  again  incision  and  drainage  will  promote  recovery.  Not 
infrequently  the  collection  will  be  found  within  the  peritoneal 
cavity  and  manifests  itself  at  some  dependent  portion — the 
pouch  of  Douglas — and  incision  and  drainage  result  in  rapid 
subsidence  of  the  symptoms.  Drainage  is  most  effectively 
accomplished  by  the  insertion  of  a  split  rubber  tube,  which 
should  be  maintained  in  place  by  a  suture  to  the  side  of  the 
vaginal  incision.  It  may  or  may  not  be  supplemented  by 
a  packing  with  iodoform  gauze.  The  latter,  alone,  soon  be- 
comes filled  with  the  exudate  and  no  longer  acts  as  a  drain,  but 
rather  as  a  tampon.  Where  careful  examination  fails  to  dis- 
close locahzation,  the  spread  of  the  infection  must  be  pre- 
vented by  absolute  rest,  ehmination  promoted  by  the  intro- 
duction of  large  quantities  of  water,  best  through  the  con- 
tinuous instillation  of  salt  solution  per  rectum,  or  where  this  is 
not  retained,  the  employment  of  hypodermoclysis.  The  in- 
testinal tract  should  be  swept  free  by  an  occasional  saline  purge. 
Increased  resistance  is  ensured  by  a  carefully  chosen  nutritious 
diet  and  the  maintenance  of  the  forces  of  the  patient.  There 
are  no  specific  remedies,  so  they  should  be  chosen  and  prescribed 
for  effect  or  to  meet  special  indications.  Efi'orts  should  be 
at  once  instituted  to  ascertain  the  cause  of  the  infection  and 
secure  means  to  combat  the  particular  organisms.  Where 
the  infection  has  become  localized  the  organism  may  be  iso- 


56  CARE  OF  GYNECOLOGIC  PATIENTS 

lated  and  cultivated  from  the  secretions,  or  in  general  infection 
the  attempt  should  be  made  to  make  cultures  from  the  blood. 
Very  frequently  such  attempts  will  be  unsuccessful,  not  be- 
cause the  organisms  have  not  entered  the  blood,  but  because 
they  attach  themselves  to  the  sides  of  the  vessels  and  are  not 
found  in  the  general  blood-current.  Where  a  culture  can  be 
secured  a  vaccine  can  be  made  from  it  and  be  utilized  to  pro- 
mote the  development  of  immunity  to  the  further  progress 
and  growth  of  the  organism  within  the  tissues  of  the  patient. 
The  emplo\Tnent  of  the  autogenous  vaccine  is  certainly  a  more 
scientific  procedure  than  the  use  of  stock  vaccines  and  bac- 
terins  which  are  prepared  by  manufacturers  and  so  loudly  pro- 
claimed to  the  profession. 

PHLEBITIS 

The  occurrence  of  inflammation  of  the  veins  producing 
thrombus,  and  later  possible  embolus,  is  another  expression 
of  sepsis.  The  saphenous  vein,  probably  most  frequently 
the  left,  is  the  situation  in  which  it  occurs  with  the  greatest 
frequency.  The  veins  of  other  parts  of  the  body  may  be 
involved,  but  in  abdominal  conditions  the  veins  of  the  legs 
are  the  ones  in  which  it  generally  originates.  I'hc  first  indi- 
cation will  be  pain  felt  over  the  saphenous  vein  in  the  groin 
or  in  the  calf  of  the  leg.  In  some  cases  the  vein  will  stand 
out  like  a  cord  and  the  presence  of  the  thrombus  will  be  ap- 
parent to  the  touch.  With  the  blocking  of  the  veins,  especi- 
ally the  femoral  and  iliac,  there  is  swelling  of  the  foot  and  Jeg, 
which  from  its  milky  glossiness  and  its  former  frequent  oc- 


PHLEBITIS  57 

currence  in  the  puerperium  is  known  as  "milk  leg."  This 
swelling  of  the  leg  is  due  to  the  blocking  of  the  return  circula- 
tion, and  will  continue  for  a  long  time  subsequent  to  the  cessa- 
tion of  the  active  inflammation  or  until  the  compensatory 
circulation  has  become  established.  Here,  again,  rest  is  abso- 
lutely indicated.  The  leg  should  be  kept  raised,  covered  with 
cotton,  and  bandaged  with  moderate  pressure.  An  ice-bag 
should  be  kept  on  the  affected  groin  and  retained  until  the 
acute  inflammation  has  subsided.  Motion  and  manipulation 
of  the  affected  parts  is  scrupulously  avoided  for  fear  of  detach- 
ing portions  of  the  clot,  which  may  be  carried  to  some  more 
important  vessel  to  block  its  caliber,  instituting  another 
thrombus.  The  occurrence  of  pulmonary  thrombus  is  most 
frequently  the  cause  of  a  fatal  result,  the  cases  of  recovery 
therefrom  bfeing  exceptional  and  very  infrequent.  One  has  no 
assurance  with  the  occurrence  of  phlebitis  as  to  the  time  of  its 
termination  and  the  possible  result.  In  the  majority  of  in- 
stances it  will  be  limited  to  the  vessels  in  which  it  originates, 
and  the  patient  recovers  with  a  leg  which  swells  when  it  is 
dependent  and  is  painful  from  the  swelling  when  much  walk- 
ing is  done.  Often  it  will  be  necessary  for  a  time  to  have  the 
leg  bandaged  when  going  about  or  wear  a  rubber  stocking. 
In  the  acute  stage,  when  the  leg  is  painful,  relief  may  be  ex- 
pedited by  enveloping  the  leg  in  cloths  wet  with  a  saturated 
solution  of  magnesium  sulphate,  covering  this  with  paraffin 
paper,  and  supporting  it  with  a  moderately  tight  bandage.  In 
the  later  stages  massage  will  be  beneficial  in.  reestablishing 
the  circulation  and  overcoming  the  tendency  to  swell  when 


58  CARE  OF  GYNECOLOGIC  PATIENTS 

dependent.  Massage  should  not,  however,  be  used  until  it 
is  evident  that  the  clot  filling  the  vessel  has  become  organized, 
for  otherwise  there  would  be  danger  of  portions  being  sepa- 
rated and  carried  to  remote  points  to  spread  the  infection,  and 
possibly  be  the  inevitable  cause  of  a  fatal  result. 

ILEUS 

Obstruction  of  the  intestines  subsequent  to  operation  is 
called  ileus,  and  usually  occurs  some  days  or  weeks  after  the 
procedure.  The  condition  is  the  result  of  adhesions  con- 
stricting, bending,  or  twisting  the  caliber  of  the  gut  so  that 
nothing  passes  through  it.  The  condition  may  be  intermit- 
tent or  continue  until  relieved  by  operative  procedure,  or  the 
patient  dies.  Ileus  has  been  described  as  adynamic  or  para- 
lytic when  due  to  paralysis  of  the  muscular  coats  of  the  intes- 
tines; dynamic  or  hyperdynamic  when  it  arises  from  tonic 
contraction  of  the  muscular  fibers;  and  mechanical  when 
produced  by  muscular  obstruction.  It  is  characterized  by 
pain,  tenderness,  and  distention  of  the  abdomen,  nausea  and 
vomiting,  and  inability  to  secure  the  passage  of  anything 
through  I  he  intestines.  The  vomitus  is  first  the  contents  of 
the  stomach,  anything  that  has  been  administered,  and  the 
regurgitation  of  bile,  and  later  the  contents  of  the  intestines 
above  the  i)oint  of  obstruction.  It  is  prone  to  occur  when 
there  has  been  a  protracted  operation  and  the  intestines  have 
been  subjected  to  prolonged  exposure  and  drying.  Exten- 
sive adhesions  broken  up  with  more  or  less  injury  of  the  peri- 
toneal surface  of  the  intestines,  wide-spread  areas  of  infec- 


ILEUS  59 

tion  which  cannot  be  completely  disinfected,  especially  when 
situated  within  the  postuterine  pouch,  cases  of  marked  enter- 
optosis,  especially  of  the  descending  colon  and  sigmoid,  may 
be  considered  as  favoring  its  occurrence.  This  is  particu- 
larly true  when  the  descending  colon  and  sigmoid  are  supplied 
with  a  mesentery  which  permits  great  freedom  of  movement. 
Intermittent  ileus  is  due  to  a  condition  which  causes  the  ob- 
struction, and  under  favorable  circumstances  again  allows 
the  passage  of  the  contents  of  the  gut  to  pass  through.  The 
latter  results  not  infrequently  from  an  adhesion  on  the  convex 
surface  of  a  coil  of  intestine,  and  then  the  peristaltic  motion  of 
the  intestines  causes  a  twist  of  this  fixed  loop  on  itself  closing 
the  canal.  Later  a  change  of  position,  or  reversed  peristalsis, 
may  undo  the  twist  and  the  difficulty  is  apparentl)^  overcome. 
Such  cases  should  be  viewed  with  suspicion,  for  the  patient 
may  at  any  time  have  another  attack.  I  have  known  such 
adhesions  to  be  the  cause  of  death  years  after  the  original 
operation.  Distention  of  the  gut  from  this  condition  leads  to 
its  softening,  occasional  rupture,  and  if  not  to  death,  to  the 
formation  of  a  fecal  fistula.  As  has  been  previously  mentioned, 
the  character  of  the  vomitus  should  be  made  known  to  the 
physician,  for  no  case  of  ileus  can  be  permitted  to  go  long  with- 
out rehef.  Lavage  will  often  afford  relief  temporarily  if  the 
obstruction  is  not  overcome  by  cessation  of  the  cause  of  ob- 
struction. Where  it  is  known  that  there  existed  some  condi- 
tion which  might  cause  partial  or  temporary  obstruction  the 
lavage  may  be  followed  by  pouring  into  the  stomach  2  ounces 
of  magnesium  sulphate  dissolved   in  an   ec^ual  quantity   of 


6o  CARE  OF  GYNECOLOGIC  PATIENTS 

water.  When  this  is  followed  by  continuous  vomiting  of  the 
intestinal  contents  without  c\-acuatiun  per  rectum,  reopening 
of  the  abdomen  should  not  be  deferred.  When  the  condition 
of  the  patient  is  bad,  and  the  adhesions  are  extensive  and  diffi- 
cult to  correct,  the  better  plan  of  procedure  is  to  draw  out  a  loop 
of  the  intestine  above  the  obstruction,  open  and  empty  it, 
after  which  a  tube  for  drainage  should  be  placed  in  each  end 
and  fastened  into  the  wound  so  that  the  canal  shall  be  effect- 
ually drained.  After  the  patient  has  improved,  a  few  days 
later,  the  obstruction  can  be  released  and  the  proper  measures 
employed  to  ensure  the  regular  passage  through  the  intestine. 
Ileus  may  be  overcome  by  simple  release  of  an  adherent  bowel, 
or  it  may  require  an  extensive  operation,  even  the  resection 
of  the  ileum  or  colon  in  order  to  secure  future  action.  The 
condition  of  the  patient  may  demand  that  a  temporary  expedi- 
ent, such  as  drainage  of  the  intestine,  be  employed  until  the 
vitality  is  sufficiently  restored  to  permit  the  operation  to  be 
completed.  In  separating  adhesions  it  should  not  be  for- 
gotten that  the  intestine  is  often  so  softened  that  it  will  tear 
Hke  wet  paper,  and  thus  cause  the  soiling  of  the  abdominal 
cavity  with  fecal  material. 

FECAL  FISTULA 

Fistulous  openings  of  the  intestine  through  the  abdominal 
wall  or  into  the  vagina  are  complications  which  sometimes 
occur  after  abdominal  operations,  and  may  be  caused  by  pre- 
vious openings  in  the  intestine,  through  which  pus  had  drained, 
or  weakened  places  in  the  wall  from  injuries  during  the  opera- 


FECAL  FISTULA  -  6 1 

tion.  As  has  been  seen,  such  openings  may  follow  ileus  and 
be  engendered  through  softening  and  rupture  of  the  bowel. 
A  fecal  fistula  is  not  infrequently  suspected  when  there  is  a 
foul- smelling  discharge  from  an  infected  wound,  especially 
where  the  intestine  has  been  \younded,  or  a  previous  fistu- 
lous opening  existed  through  which  there  has  been  drain- 
age into  the  bowel  from  a  suppuratmg  sac.  A  collection 
of  blood  or  serum  beneath  the  muscle  infected  with  the 
colon  bacillus  affords  a  discharge  which  will  have  the  odor  of 
the  contents  of  the  bowel,  and  with  the  flakes  of  blood  and 
sloughing  membrane  readily  leads  to  an  incorrect  diagnosis 
of  fecal  fistula.  The  occurrence  of  a  fistula  should  not  be 
considered  an  indication  for  hasty  action,  as  unless  there  is 
a  flexion  and  such  obstruction  of  the  intestine  as  to  make  the 
passage  of  its  contents  difficult,  the  fistula  will  close  without 
operative  interference.  When  it  is  evident  that  interference 
will  be  necessary  to  ensure  relief  from  the  offensive  soiling  of 
the  person,  the  abdomen  should  be  opened,  the  intestine  set 
free  from  its  adhesions,  and  if  constricted  the  contracted 
portion  should  be  excised  and  an  anastomosis  perfomied. 
Under  no  circumstances  should  an  attempt  be  made  to  close 
an  enteric  fistula,  whether  abdominal  or  vaginal,  without  ex- 
posing the  constricted  intestine.  The  fact  that  the  fistula  has 
not  healed  is  evidence  that  the  fecal  contents  have  difficulty 
in  passing  the  obstruction,  and  indicates  the  necessity  for  open- 
ing the  abdomen  to  set  free  the  imprisoned  structures. 


ABDOMINAL   AND   PELVIC    OPERATIONS 

SHORTENING   THE   ROUND   LIGAMENTS 

Instruments. — See  Fig.  9. 

This  operation  generally  involves  the  round  ligaments, 
although  the  broad  ligaments  and  uterosacral  ligaments  may 
be  subjected  to  shortening.  The  term  here  will  be  confmed  to 
the  round  ligaments,  and  the  procedure  to  the  one  known  as 
the  Montgomery  modification  of  the  Gilliam  operation.  The 
abdomen  is  opened  by  either  the  median  or  Pfannensticl  in- 
cision, and  after  the  packing  back  of  the  intestines  and  the 
separation  of  the  wound  with  the  self-retaining  retractor  the 
ligaments  are  under  view  (Fig.  10).  The  operator  picks  up 
the  round  ligament  with  tissue  forceps  about  ij  inches  from 
the  uterine  cornu,  and  with  a  needle  threaded  with  No.  i 
chromic  catgut  passes  a  suture  beneath  it.  The  two  ends  of 
this  suture,  about  6  inches  long,  are  grasped  with  a  hemostat 
by  the  intern  and  dropped.  The  operator  passes  a  ligature 
under  the  other  ligament  and  threads  its  two  ends  into  the 
eye  of  the  modified  Deschamp  needle,  which  the  nurse  has 
handed  him,  grasps  the  round  ligament  with  a  hemostat  just 
external  to  the  insertion  of  the  ligature,  which  is  handed  to  the 
intern   to  hold  tense,  while  the  operator  with  tissue  forceps 

picks  up  the  anterior  fold  of  peritoneum  in  front  of  the  round 
62 


SHORTENING  THE  ROUND  LIGAMENTS 


63 


ligament,  cuts  a  small  opening  in  it,  through  which  he  carries 
the  Deschamp  needle  threaded  with  the  two  ends  of  the  tem- 


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porary  ligature  outwardly  beneath  the  round  ligament  until 
its  point  reaches  the  position  of  emergence  of  the  ligament, 
when  he  drives  the  instrument  through  the  abdominal  wall, 


64 


CARE  OF  GYNECOLOGIC  PATIENTS 


bringing  it  out  upon  the  aponeurosis,  at  the  same  time  hold- 
ing back  the  skin  and  superficial  fascia  (Fig.  ii).  The  intern 
removes  the  forceps  from  the  round  ligament  and  places  them 


Fig.  lo.  MiiiiiL'umir\-'s  methoil  of  -iKuicniii.i,'  tin-  round  ligamciit>.  Round 
ligament  fixed  with  inmoslat  while  temporary  ligature  is  carried  beneath  anterior  leaflet 
of  broad  ligament  with  a  Deschamp  needle.    (Montgomery,  "Practical  Gynecology.") 

on  the  ends  of  the  temporary  suture  as  soon  as  it  has  been 
unthreaded  from  the  needle.  The  intern  takes  the  forceps 
from   the   suture   and  applies  them  to  the   round  ligament, 


SHORTENING  THE  ROUND  LIGAMENTS 


65 


while  the  operator  threads  the  needle  and  then  opens  the 
broad  ligament,  and  carries  the  suture  through  the  tissues  as 
described    for    the   first   Hgament.      The   last   ligature    thus 


Fig.  II. — Montgomery's  method  of  shortening  the  round  ligaments.     Loop  secured  on 
the  aponeurosis.     (Montgomery,  "Practical  Gynecology.") 

brought  through  is  grasped  by  the  operator  and  drawn  tense. 
The  intern  pushes  back  the  skin  and  superficial  fascia,  while 
the  operator  inserts  a  sharp-pointed  scissors  along  the  suture 


66  CARE  OF  GYNECOLOGIC  PATIENTS 

and,  slightly  separating  the  points,  opens  the  fascia  so  that 
the  loop  of  round  ligament  is  easily  drawn  through.  The 
superficial  fascia  is  pushed  back,  exposing  the  glistening  surface 
of  the  aponeurosis,  to  which  the  ligament  loop  is  fastened  by 
a  suture  on  either  side,  each  suture  taking  up  the  distal  and 
proximal  ends  of  the  loop.  These  sutures  tied,  the  temporary 
suture  is  withdrawn,  and  the  Ugature  of  the  other  side  is 
similarly  treated.  All  packing  is  now  removed,  and  the  nurse 
asked  to  make  known  whether  all  gauze  packs  or  sponges  are 
in  sight.  The  pelvis  carefully  inspected,  the  appendix  may  be 
brought  up,  inspected,  and  if  deemed  desirable,  removed.  (In 
the  great  majority  of  cases  its  removal  is  wise.)  If  it  is  to  be 
removed,  the  operator  passes  one  blade  of  a  hemostat  beneath 
its  base,  clamps  it,  and  hands  this  to  the  intern,  while  he  grasps 
the  meso-appendix  with  another,  and  then  cuts  through  the 
latter  between  the  forceps  and  the  appendix.  A  ligature  of 
chromic  catgut  is  tied  about  this  below  the  forceps,  which  the 
intern  is  directed  to  loosen  slowly,  and  the  knotting  is  com- 
pleted. A  ligature  is  thrown  around  the  base  of  the  appendix 
below  the  forceps,  which  the  intern  removes  and  applies  higher 
up.  The  ligature  is  tied  firmly  and  the  appendix  cut  across, 
leaving  a  ligated  stump.  The  appendix  and  infected  scissors 
are  taken  away.  The  stump  is  carbolized,  the  superfluous 
acid  removed  with  a  gauze  pad,  and  then  with  a  round-pointed 
needle  the  peritoneum  above  the  stump  is  picked  up  by  a 
purse-string  suture,  into  which  the  stump  is  pushed  and  the 
ligature  tied,  shutting  it  off  from  the  peritoneal  cavity.  Dur- 
ing this  procedure  gauze   is  kept  about  the  appendix,   the 


SALPINGECTOMY— SALPINGO-OOPHORECTOMY  67 

forceps  grasp  it  just  above  where  it  is  cut  off,  and  the  stump  is 
immediately  squeezed  with  a  gauze  pad,  accomplishing  the 
operation  without  any  danger  of  infection.  Through  the 
abdominal  incision  the  gall-bladder  and  the  epigastric  region 
may  be  explored  with  the  hand. 

SALPINGECTOMY— SALPINGO-OOPHORECTOMY 

Instruments. — See  Fig.  12. 

The  median  incision  should  only  be  employed  for  two 
reasons:  First,  the  presence  of  infection  may  render  the 
transverse  incision  difficult  to  protect  from  contact  with  the 
affected  tissue  or  hands.  Second,  the  exigencies  of  the 
procedure  may  require  more  room  for  manipulation  than 
can  be  secured  with  the  transverse  incision  with  proper 
regard  for  the  future  of  the  patient. 

The  intestines  and  the  general  cavity  must  be  carefully 
walled  off,  and  this  ma>'  have  to  be  done  before  the  separa- 
tion of  the  intestines  and  omentum,  for  these  structures  may 
serve  to  form  part  of  the  wall  of  the  abscess  collection.  Gauze 
pads  should  be  applied  beneath  the  retractor  on  either  side 
to  protect  the  abdominal  incision  from  the  infective  mate- 
rial. In  recent  inflammation  the  coils  of  intestine  and  the 
omentum  may  be  sponged  away  from  the  bladder,  tubes, 
ovaries,  and  uterus,  but  in  old  cases  the  aid  of  scissors  may 
be  required  to  complete  the  separation.  Adhesive  bands 
should  be  cut  with  scissors,  and  with  care  not  to  injure  intes- 
tines. The  section  of  the  bands  affords  an  opportunity  to 
reach  less   firm   adhesions   which   can  be   readily  separated 


68 


CARE  OF  GYNECOLOGIC  PATIENTS 


with   the  finger  or   the  point  of  closed  blunt  scissors.     As 
the  structures  are  separated  they  are  walled  back.     The  fun- 


2  8  g 


dus  reached,  the  fingers  should  hug  it  closely,  and  thus  secure 
a  line  of  cleavage  which  will  permit  separation,  and  after- 


S.\LPINGECTOMY— SALPINGO-OOPHORECTOMY  69 

ward  permit  the  posterior  surface  of  the  broad  ligament  to 
be  followed,  setting  free  the  infected  tubes  and  ovaries.  By 
pressing  the  uterus  downward  and  drawing  upward  upon 
the  intestines,  bands  of  adhesions  may  be  cut  without  in- 
jury to  the  viscera.  Pus,  blood,  and  inflammatory  exudate 
should  be  kept  wiped  away  as  the  operation  proceeds,  so 
that  infection  shall  not  be  distributed  through  the  abdomen. 
Not  infrequently  openings  will  be  found  in  the  intestine 
through  which  drainage  has  taken  place.  Even  where  no 
such  discharge  has  occurred,  careful  inspection  should  be 
made  to  see  that  no  softened  points  exist  where  perforation 
was  about  to  occur.  Openings  in  the  intestine  should  be 
pared  and  closed  at  once.  The  opening  should  be  raised  up, 
its  edges  pared  or  freshened  with  curved  scissors,  and  then 
sutured  with  a  round-pointed  curved  needle  threaded  with 
sterile  silk,  and  the  intestine  folded  over  this  line  of  suture 
with  a  fme  chromic  catgut  suture.  Where  the  ovaries  and 
tubes  are  broken  down  with  infection,  they  should  be  re- 
moved, but  an  ovary  or  part  of  one  should  always  be  retained 
if  possible  to  maintain  the  balance  of  internal  secretions. 
Ragged  omentum  should  be  tied  and  the  ends  cut  off.  The 
intestine  must  be  carefully  inspected  for  injuries  and  also  to 
ensure  separation  of  the  coils,  so  that  subsequent  obstruction 
may  not  occur.  Where  the  intestine  is  severely  injured,  has 
been  the  seat  of  extensive  inflammatory  thickening,  so  that 
its  permeability  is  threatened,  it  may  be  wise  to  resect  it. 
Last  year  I  had  a  patient  in  the  ward  who  had  some  years 
previously   undergone    an    abdominal    operation,    and    as   a 


70  CARE  OF  GYNECOLOGIC  PATIENTS 

result  came  into  the  house  suffering  from  obstruction.  The 
abdomen  opened  disclosed  a  knuckle  of  small  intestine  coiled 
about  a  section  of  the  descending  colon  so  that  its  caliber  was 
completely  closed.  I  was  able  to  separate  the  intestines  so 
that  the  canal  was  no  longer  obstructed,  but  the  descending 
colon  formed  so  large  a  loop,  loosely  attached,  with  a  meso- 
colon so  long  as  to  permit  a  volvulus  to  recur  readily,  that  I 
decided  to  remove  the  redundant  portion.  It  was  separated 
from  its  mesocolon  and  about  i8  inches  of  the  intestine 
removed.  The  procedure  was  as  follows:  The  amount  of 
intestine  was  estimated  by  bringing  the  surfaces  together, 
showing  the  amount  that  could  be  spared.  Intestinal  clamps 
were  applied  at  these  points,  and  after  the  mesocolon  had 
been  tied  and  severed  in  sections  between  the  points,  the  in- 
testine was  divided  between  forceps,  the  surrounding  sur- 
faces previously  protected  with  gauze  pads.  The  peritoneum 
of  the  cut  ends  retracting,  the  muscle  and  mucous  membrane 
were  tied,  closing  the  open  end,  carbolized,  and  after  squeez- 
ing off  the  superfluous  acid  the  peritoneum  was  sutured  over 
the  end.  The  ends  of  the  intestine  were  then  overlapped 
and  a  lateral  anastomosis  done.  With  a  fine  chromic  catgut 
(No.  o)  suture  the  surfaces  were  united  for  a  distance  of 
6  cm.,  then,  having  pushed  their  contents  back,  clamp  for- 
ceps were  appUed  and  the  surfaces  carefully  protected  with 
gauze  pads,  each  portion  of  the  intestine  opened  the  length 
of  the  suture,  and  the  raw  edges  of  the  adjacent  portions 
sutured  with  a  continuous  silk  suture.  This  was  continued 
around  the  remaining  edges  of  the  opening,  and  when  the 


SALPINGECTOMY— SALPINGO-OOPHORECTOMY  7 1 

intestinal  communication  was  complete  the  catgut  suture 
was  resumed,  completing  the  external  row  of  suturing.  The 
clamps  were  removed  and  the  patency  of  the  communica- 
tion determined,  the  cavity  carefully  examined,  and  all  for- 
eign bodies  removed. 

The  removal  of  the  tube  alone  is  salpingectomy.  The 
removal  of  tube  and  ovary  is  salpingo-oophoredomy.  The 
ligation  of  the  pedicle  in  the  latter  operation,  where  the 
broad  ligament  is  infected  and  filled  with  exudate,  may  be 
attended  with  some  difficulty  as  the  broad  Ugament  is  short- 
ened and  held  down.  Sometimes  it  is  better  to  incise  the 
peritoneum  and  draw  out  the  infected  tube  from  its  sheath. 
The  assistant  must  be  ready  with  a  hemostat  to  seize  any 
bleeding  vessels.  The  application  of  a  ligature  is  difficult 
and  is  likely  to  cut  out.  The  better  plan  is  to  suture  the 
surfaces  with  a  continuous  suture  of  catgut  which  should 
not  be  drawn  so  tight  as  to  cut  through.  In  cases  of  ex- 
tensive pelvic  infection  there  is  quite  frequently  extensive 
oozing  and  the  possibiHty  that  collections  may  form  to  be- 
come infected  from  the  surrounding  tissue,  or  from  its  rela- 
tion to  the  coils  of  intestine,  so  that  it  is  preferable  that 
vaginal  drainage  shall  be  employed.  A  spHt  rubber  drain 
may  be  carried  through  the  pelvis  into  the  vagina,  and  when 
the  pelvic  peritoneum  is  much  broken  it  may  be  supple- 
mented by  gauze  packing,  one  end  of  which  is  carried  into 
the  vagina.  The  gauze  thus  used  keeps  the  intestines  from 
coming  in  contact  with  the  injured  surfaces  until  the  perito- 
neum has  had  opportunity  to  re-form.     It  is  wise  to  employ 


72 


CARE  OF  GYNECOLOGIC  PATIENTS 


such  drainage  when  the  intestine  has  been  injured  and 
sutured,  especially  where  there  has  been  a  previous  drain- 
age into  the  intestine,  for  the  intestinal  wall  in  such  instances 
is  not  very  resisting  and  may  break  down.  If  no  vent  has 
been  provided,  the  pelvis  is  infected  by  the  drainage  of  fecal 
matter,  which,  if  nothing  worse  occurs,  will  make  its  exit 
through  the  abdominal  wound,  infecting  its  full  length. 


Fig.  13. — Salpingostomy. 


The  rule  of  surgical  procedure  should  be  to  remove  struc- 
tures which  are  in  so  diseased  a  condition  as  to  ensure  con- 
tinual infection  where  retained,  but  in  chronic  conditions 
where  infective  processes  have  subsided  and  result  in  closure 
of  the  abdominal  end  of  the  tube,  it  should  not  be  sacrificed, 
but  should  l)e  opened.  Unless  the  fimbria  can  be  set  free 
by  separating  adhesions  about  the  abdominal  end  of  the 
tube,  a  fistula  should  ])e  formed  by  a  longitudinal  incision  on 
its  convex  border.     The  circular  fibers  hold  open  the  incision 


OVARIOTOMY 


73 


and  evert  its  mucosa.     This  procedure  is  known  as  salpin- 
gostomy (Fig.  13). 

OVARIOTOMY 

This  is  the  term  employed  for  the  removal  of  tumors  of 
the  ovary  (Fig.  14). 

For  instruments  and  preparations,  see  Fig.  15. 

These  tumors  may  attain  to  a  very  large  size,  may  be  single 
or  multiple;  the  contents  may  be  thin,  or  thick  and  viscid, 


Fig.  14. — Woman  with  large  ovarian  cyst. 


with  fatty  matter,  teeth,  hair,  and  bones.  The  growths  may 
be  benign  or  malignant.  Unless  the  tumor  is  of  enormous 
size  it  is  better  to  make  the  incision  large  enough  that  the 
sac  can  be  turned  out  without  being  opened.  This  is  par- 
ticularly true  in  the  dermoid  growths,  in  which  the  contents 


74 


CARE  OF  GYNECOLOGIC  PATIENTS 


arc  frequently  fatty  acids,  so  irritating  that  contact  of  the 


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fluid  with  the  peritoneum  is  sure  to  set  u})  intlammation  and 
be  followed  by  peritonitis.     In  malignant  growths,  the  soiling 


OVARIOTOMY  75 

of  the  peritoneum  with  the  contents  may  be  followed  with 
secondary  implantation  and  the  recurrence  of  the  disease. 
In  a  unilocular  cyst  a  short  incision  may  be  succeeded  by 
puncture  and  evacuation  of  the  cyst  and  the  withdrawal  of 
its  sac  through  a  small  opening.  The  intern  should  be  di- 
rected to  place  his  hands  on  either  side  of  the  upper  abdomen 
and  press  the  sac  of  the  tumor  into  the  incision,  and  under 
no  circumstances  to  let  up  on  the  pressure.  The  operator 
with  a  knife  punctures  the  cyst,  when  with  cyst  or  Ochsner 
forceps  he  seizes  its  edges  at  the  puncture  and  draws  it  out. 
The  sac  thus  forms  its  own  funnel  and  the  soiling  of  the 
cavity  is  prevented.  When  the  tumor  is  removed  unopened, 
it  should  be  held  by  the  intern  and  not  be  allowed  to  drag 
on  its  pedicle;  the  latter  should  be  clamped  with  large  and 
strong  forceps  and  be  cut  between  the  forceps  and  the  tumor 
(Fig,  16).  As  the  tumor  is  withdrawn,  adhesions  of  the 
intestines  must  not  be  overlooked.  These  adhesions  when 
recent  are  easily  separated,  but  old  adhesions  may  be  so 
firm  as  to  require  the  employment  of  scissors  to  separate  them. 
They  may  be  so  intimate  as  to  require  a  portion  of  the  cyst 
wall  to  be  removed  with  them  to  save  the  intestine  from  in- 
jury. The  secreting  surface  should  be  removed  from  all 
such  portions.  The  tumor  may  not  always  have  a  pedicle 
and  may  have  to  be  enucleated.  The  tumor  may  be  intra- 
ligamentary,  and  in  its  development  spread  out  the  broad 
ligament,  causing  the  ureter  to  lie  over  a  portion  of  its  sur- 
face. The  situation  of  the  ureter  should  be  determined  in 
all  intraligamentary  growths.     Such  a  tumor  may  have  so 


76  CARE  OF  GYNECOLOGIC  PATIENTS 

spread  out  the  uterus  upon  its  surface  as  to  require  the  re- 
moval of  the  organ  to  secure  the  extirpation  of  the  growth. 
In  the  removal  of  the  unopened  tumor  I  would  advise  that 
a  pair  of  forceps  be  applied  to  its  jicdicle.  This  is  tied  with 
chromic  catgut.  The  operator,  having  such  a  suture  threaded 
in  a  needle,  passes  it  through  the  pedicle  and  ties  it  in  two 


Fig.  1 6. — Ovarian  tumor  which  was  removed  without  puncture. 

portions,  and  finally  carries  one  of  the  ligatures  around  the 
stump  and  ties  again.  The  peritoneum  is  sutured  over  the 
stump  with  fme  chromic  catgut  suture  to  prevent  a  coil  of 
intestine  becoming  adherent  to  the  raw  surface.  The  peri- 
toneum is  carefully  inspected  for  bleeding  points  and  for 
injuries,  all  of  which  should  be  covered  in. 


THE  PACIFIC  COAb.  ...o... 
OF  NURSING 

HYSTERECTOMY— SUBTOTAL  HYSTERECTOMY      77 

HYSTERECTOMY— PANHYSTERECTOMY— SUBTOTAL 
HYSTERECTOMY 

Hysterectomy  is  indicated  for  cancer  of  the  cervix  and 
body,  for  fibroid  growths,  and  in  inflammatory  cases  where 
the  uterus  is  so  infected  that  it  cannot  be  retained  without 
prejudice  to  the  health  and  even  Hfe  of  the  affected  individual. 
It  means  the  removal  of  the  organ  in  whole  or  part.  The 
partial  removal  is  known  as  hysterectomy  subtotal  or  supra- 
vaginal, and  should  not  be  practised  when  the  uterus  or  any 
portion  of  it  is  invaded  by  malignant  disease.  The  entire  re- 
moval of  the  organ  is  known  as  panhysterectomy,  and  may  or 
may  not  be  accompanied  by  the  removal  of  the  ovaries  and 
tubes. 

For  instruments  and  preparations,  see  Fig.  17. 

The  median  abdominal  incision  is  preferable,  inasmuch 
as  it  affords  more  room.  The  intestines  are  packed  back 
and  the  myoma  screw  inserted,  by  which  the  uterus  and 
growth  are  drawn  up.  This  instrument  should  not  be  used 
in  malignant  disease  of  the  body.  The  uterus  is  drawn  to- 
ward the  umbilicus,  the  anterior  surface  exposed,  and  the 
self-retaining  retractor  inserted.  The  intern  makes  trac- 
tion on  the  uterus,  when  the  operator  with  tissue  forceps 
picks  up  the  peritoneum  above  the  bladder  and  incises  it 
outwardly  on  each  side  to  the  round  ligament.  The  round 
ligaments  are  tied  and  cut;  a  ligature  is  passed  through  the 
broad  ligament  between  the  ovary  and  uterus  in  fibroids,  and 
external  to  the  ovary  in  cancer,  tied  and  cut;  the  mass  is  then 
raised  up,  the  uterine  arteries  exposed,  clamped,  and  cut. 


78 


CARE  OF  GYNECOLOGIC  PATIENTS 


In  partial  hysterectomy  the  uterus  is  cut  across  at  this  point, 
leaving    the   stump    of    the    cervix    (Fig.    18).     The   uterine 


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arteries  are  tied.      The  nurse  hands  a  curved  needle,  armed 
with  catgut  ligature,  which  is  passed  through  the  posterior 


HYSTERECTOMY— SUBTOTAL  HYSTERECTOMY 


79 


peritoneum,  carried  alongside  the  stump  through  the  perito- 
neum in  front  near  the  round  ligament;  then  with  a  hemostat 
the  intern  holds  the  stump  of  the  broad  ligament  so  that  the 


Fig.   1 8. — Exposing  the  cervix  in  subtotal  hysterectomy.     (Montgomery,   "Practical 

Gynecology.") 

ligature  is  tied  over  it,  thus  ensuring  against  hemorrhage 
by  a  second  ligature,  and  making  the  stump  of  the  ligament 
support  the  cervix  and  vagina  against  subsec[ucnt  prolapse 


So 


CARE  OF  GYNECOLOGIC  PATIENTS 


(Fig.  19).  The  same  course  is  followed  on  the  other  side, 
and  the  intervening  peritoneal  edges  closed  with  a  continuous 
suture. 

Panhysterectomy. — Following  the  course  indicated  above, 
the  uterosacral  ligaments  are  clamped  and  cut,  which  per- 
mits the  uterus  to  be  raised,  attached  to  the  vagina  alone. 


Fig.  19. — Stumps  of  the  broad  ligament  sutured  to  the  cervix.     Peritoneum  closed 

over  them  on  the  left  side. 

The  latter  may  be  opened  behind,  in  front,  or  on  the  side,  and 
separated  from  the  cervix.  When  the  operation  is  done  for 
malignant  conditions  it  is  important  to  guard  against  reim- 
plantation of  the  disease,  so  that  the  vagina  should  be  care- 
fully mopped  out,  clamped  below  the  cervbc,  and  the  canal 
cut  across  below  the  clamps.     I  think  an  equally  effective 


HYSTERECTOMY— SUBTOTAL  HYSTERECTOMY 


8l 


procedure  is  to  open  the  vagina  in  front,  push  a  gauze  pad 
through  the  opening  into  the  vagina,  which  is  subsequently 
to  be  withdrawn  through  the  vulva,  pack  some  gauze  over 
the  cervix,  and  complete  the  section.  The  tissues  are  thus 
protected  from  contact  with  diseased  tissue.  Sutures  are 
passed  on  either  side  of  the  pelvis,  picking  up  the  perito- 


Fig.  20. — Method  of  fixing  stumps  in  panhysterectomy. 

neum,  posteriorly  carried  forward  along  the  edges  of  the 
vagina  and  including  the  vesico-uterine  peritoneum.  The 
stumps  of  the  broad  ligaments  are  drawn  inward  and  the 
ligature  suture  tied  over  each.  The  intervening  peritoneum 
is  secured  by  a  continuous  suture  (Fig.  20). 


82  CARE  OF  GYNECOLOGIC  PATIENTS 

INTESTINAL  RESECTION  AND   ANASTOMOSIS 

Excision  of  a  portion  of  the  intestine  may  be  demanded 
for  injuries  during  the  progress  of  an  operation  for  inflam- 
matory conditions,  or  extensive  adhesions  in  ovarian  or  uter- 
ine neoplasms  where  the  destruction  of  the  intestinal  walls 
or  the  injuries  to  vessels  have  been  so  extensive  as  to  im- 
peril the  future  vitality  of  the  intestine. 

The  primary  purpose  of  the  operation  may  have  been  to 
resect  the  intestine  for  obstruction  from  malignant  disease; 
for  volvulus;  for  intussusception,  or  strangulation  from  con- 
stricting bands,  or  from  hernia;  for  redundant  condition  of 
the  descending  colon  or  sigmoid;  for  prolapsus  of  large  por- 
tions which  are  frequently  an  intussusception  of  the  sigmoid 
and  colon  through  the  anus.  Resection  and  anastomosis 
have  of  late  been  suggested  by  Lane  for  intestinal  stasis  and 
toxemia,  where  he  partially  or  completely  removed  the  colon. 

For  instruments  and  preparations,  see  Fig.  21. 

The  abdomen  is  opened  in  the  median  line,  whether  the 
procedure  is  primary  or  secondary.  In  the  latter  the  in- 
testinal work  follows  the  removal  of  the  inflammatory  struc- 
tures or  growths,  as  the  case  may  be.  The- intestine  affected 
is  raised,  its  contents  pressed  or  milked  downward  where 
there  is  no  opening,  but  where  one  exists  it  is  brought  out  of 
the  wound  and  the  intestine  emptied  through  it,  exercising 
care  that  the  contents  do  not  enter  and  soil  the  peritoneal 
cavity.  Clamps  are  aj^plied  to  the  intestine  beyond  the  points 
at  which  excision  is  i)roposed  and  a  pair  of  forceps  at  each 
end  of  the  portion  of  the  gut  to  be  removed.     The  intestine 


INTESTINAL  RESECTION  AND  ANASTOMOSIS 


83 


is  cut  between  forceps  at  either  end  of  the  proposed  resection, 


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and    the   excised   portion   separated    from    its   mesentery   or 
mesocolon,  as  the  case  may  be,  and  the  vessels  clamped  as 


84  CARE  OF  GYNECOLOGIC  PATIENTS 

the  separation  proceeds.  Care  is  exercised  to  make  this 
separation  hug  closely  the  bowel,  so  that  large  branches  shall 
not  be  injured,  and  thus  imperil  the  vitaUty  of  extensive  por- 
tions of  the  intestine.  The  nurse  hands  a  suture  ligature  of 
chromic  catgut  No.  i,  threaded  in  a  round-pointed  needle, 
and  the  mesentery  is  secured  with  a  continuous  suture  occa- 
sionally interlocked  by  passing  the  needle  and  suture  be- 
neath the  preceding  loop.  After  tying  the  end  of  the  suture, 
the  surface  should  be  inspected  to  make  certain  that  all  bleed- 
ing is  controlled.  The  proximal  and  distal  ends  of  the  re- 
sected gut  are  carefully  cleansed  when  cut.  The  muscle  and 
muscle  layer  of  each  are  now  seized  with  forceps,  drawn  out 
from  the  peritoneum,  tied  with  silk,  having  the  forceps  slowly 
loosened  as  the  knot  is  tied,  the  external  portion  carbolized, 
dried,  and  the  peritoneum  sutured  over  it.  The  intestinal 
clamps  are  placed  some  3  inches  from  the  distal  and  proximal 
ends  of  the  intestine,  the  contents  having  been  pushed  beyond 
the  clamps  before  they  are  appHed.  The  intestinal  ends  are 
overlapped  and  the  peritoneal  surfaces  sutured  for  a  space  of 
3  to  4  cm.  An  incision  is  made  in  each  end  the  length  of  the 
sutured  portion,  when  the  field  having  been  protected  by  gauze, 
the  edges  of  the  incision  arc  united  by  a  continuous,  occa- 
sionally interlocked  silk  suture,  tied  on  the  inner  surface. 
When  the  opening  is  completely  closed  the  catgut  suture  is 
resumed,  uniting  the  peritoneal  surfaces  over  the  silk  suture 
(Fig.  22).  The  clamps  are  removed,  the  certainty  of  the 
communication  established  by  pressing  the  gas  and  con- 
tents of  the  upper  intestine  downward  through  the  opening. 


INTESTINAL  RESFXTION  AND  ANASTOMOSIS 


85 


The  wound  in  the  mesentery  is  closed  by  a  continuous  catgut 
suture.  The  same  course  is  pursued  in  resection  for  non- 
traumatic conditions.  When  done  because  of  strangulation, 
the  precaution  must  be  exercised  to  make  certain  that  the 
resection  has  extended  beyond  the  devitalized  portion. 

In  operations  for  carcinoma  or  prolapsus  of  the.  rectum 
it  may  be  necessary  to  loosen  the  peritoneum,  and  resect  the 


Fig.  22. — Intestines  united  by  lateral  anastomosis. 


bowel  below  the  latter,  where  it  is  not  feasible  to  apply  clamps 
to  the  lower  portion.  The  sphincter  should  have  been  pre- 
viously divulsed  and  the  wound  cleansed  from  below.  Where 
the  bowel  is  opened  a  gauze  pad  should  be  pushed  into  the 
lower  segment,  to  be  withdrawn  by  the  anus,  and  the  pelvis 
carefully  protected  from  soiling  by  gauze  packing.  The 
resection  may  be  so  low  in  the  pelvis  as  to  make  even  an  end- 
to-end  anastomosis  difhcult.     In  such  cases  the  better  pro- 


86  CARE  OF  GYNECOLOGIC  PATIENTS 

cedure  is  to  draw  the  proximal  portion  of  the  intestine  through 
the  anus.  Its  ends  should  have  been  ligated  temporarily  to 
ensure  protection  of  the  pelvis  from  soiling.  The  abdominal 
wound  shoukl  be  temporarily  packed  with  gauze  while  the 
end  of  the  intestine  is  being  stitched  to  the  skin  about  the 
anus.  The  hands  are  washed,  or  the  gloves  changed  when 
they  are  worn,  and  the  peritoneum  sutured  in  the  pelvis  about 
the  intestine,  following  which  the  abdominal  wound  is  closed. 
The  intussuscepted  portion  of  the  intestine  sloughs  and  is  dis- 
charged through  the  anus.  It  is  better  to  fasten  a  rubber 
drain  through  the  anus  into  the  intestine  for  a  few  days  to 
prevent  gaseous  distention  of  the  lower  bowel. 

GASTRIC   OPERATIONS 

Operations  on  the  stomach  consist  in  measures  for  its 
support  in  prolapsus;  its  exploration  for  removal  of  foreign 
bodies  and  the  treatment  of  ulceration;  its  resection  in  cancer 
and  extensive  ulceration,  and  its  drainage  in  narrowing  of  the 
pyloric  opening  or  in  marked  prolapse  and  dilatation.  The 
incision  should  generally  be  made  above  the  umbilicus,  in 
the  median  line  or  through  the  left  rectus.  The  incision 
should  be  a  free  one,  for  a  large  incision  can  be  closed  more 
expeditiously  and  with  less  injury  to  the  structures  than 
when  the  operation  is  done  through  a  small  and  insuflficient 
opening.  As  it  is  quite  impossible  to  absolutely  predict  in 
advance  the  character  and  extent  of  an  operation,  it  is  a 
matter  of  prudence  to  be  provided  with  all  the  necessary 
paraphernalia  for  any  emergency. 


GASTRIC  OPERATIONS 


87 


For  instruments  and  preparations,  see  Fig.  23. 


Fig.  23. — Instruments  and  preparations  for  gastric  procedures:  i,  Scalpel;  2,  scissors, 
curved  and  straight,  sharp  and  blunt  pointed  (4):  3,  hemostatic  forceps  (12);  4,  long  hemo- 
static forceps  (Bland's)  (4);  5,  large  gastro-entero-^tomy  clami:)S  (2);  6,  small  gastro  enteros- 
tomy clamps  (2);  7,  large  clamp  forceps  (2);  S,  combined  retractors  (self-retaining);  y,  broad 
blade  retractors  (2);  10,  abdominal  retractors  (2)-  11,  small  retractors  for  holding  open  the 
stomach  (4);  12.  ligature  carriers  (right  and  left);  13,  tissue  forcep'^,  toothed  (2),  serrated  (il; 
14,  needle-holder;  15,  towel  clips  (6),  16,  needles,  curved,  round-pointed  (4):  17,  needles, 
long  and  curved,  cutting  edge  (4);  18,  Paquelin  cautery;  ig,  tubes  of  silk  for  sutures,  Nos.  o, 
I,  2;  20,  tubes  of  catgut,  chromic,  Nos.  o,  i,  2;  21,  tubes  of  catgut,  plain,  Nos.  i,  2;  22,  pack- 
ages containing  sterile  gowns,  sponges,  packs,  dressings,  towels,  sheets,  cover  pad,  and  abdom- 
inal binder.     Plaster  in  strips  with  tapes  attached  for  retaining  dressings. 


Gastropexy. — In  gastroptosis  the  stomach  is  supported 
by  folding  the  gastrohepatic  omentum,  as  suggested  by 
Beyea,  or  attaching  the  great  omentum  to  the  anterior  ab- 


88 


CARE  OF  'GYNECOLOGIC  PATIENTS 


dominal  wall.  The  patient  is  placed  in  the  dorsal  position, 
with  the  upper  part  of  the  table  slightly  elevated,  or  the 
table  may  be  broken  about  the  middle  of  the  back,  or  a  sand 
pillow  or  inflated  rubber  pillow  placed  under  the  patient,  so 
that    the   upper   abdomen   is   more   prominent.     A    median 


Wl  1  ^  \^ 


/ 


X 


Fig.  24. — Beyea's  operation  for  gastroptosis — the  first  layer  of  sutures  (Moynihan). 

incision  from  the  ensiform  cartilage  to  just  above  the  umbili- 
cus is  made  through  all  the  tissues  above  the  peritoneum. 
The  latter  is  held  with  tissue  forceps  by  the  operator  and 
intern  and  opened  between  them.  The  operator  then,  with 
blunt  straight  scissors,  incises  the  peritoneum  the  length  of 


GASTRIC  OPERATIONS 


89 


the  wound,  protecting  the  abdominal  contents  with  two 
lingers  of  the  other  hand.  He  raises  up  the  stomach,  trans- 
verse colon,  and  omentum,  and  with  a  pack  handed  him  by 
the  nurse  walls  off  the  small  intestine.  The  intern  and  a 
nurse  hold  the  wound  open  with  a  broad  retractor  on  either 


Fig.  25. — Beyea's  operation  for  gastroptosis — the  first  layer  of  sutures  completed;  the 
second  and  third  being  introduced  (Moynihan). 

side  (Figs.  24,  25).  The  operator  carefully  examines  the 
stomach,  pylorus,  and  gall-bladder,  after  which  he  shortens 
the  gastrohepatic  omentum  by  inserting  three  rows  of  sutures, 
using  No.  I  chromic  catgut,  threaded  in  a  curve-pointed 
needle,  exercising  great  care  not  to  include  large  vessels  in 
the  sutures. 


90 


CARE  OF  GYNECOLOGIC  PATIENTS 


The  Coffey  operation  consists  in  stitching  the  omentum 
to  the  anterior  abdominal  wall,  this  forming  a  sort  of  shelf  on 
which  the  stomach  shall  rest  (Fig.  26).  The  omentum  just 
below  the  colon  is  secured  by  interrupted  sutures  to  either 
side  and  to  the  wound  as  it  is  closed,  exercising  the  precau- 


Fig.  26. — Gastropexy;  Coffey's  operation.     The  suture  of  the  omentum  to  the  anterior 

abdominal  wall  (Moynihan). 

tion  that  there  shall  remain  no  opening  through  which  a  loop 
of  the  small  intestine  may  be  forced  and  become  strangu- 
lated. Where  the  omentum  is  very  heavy  and  fat  this  oper- 
ation may  very  wisely  supplement  the  Beyea  procedure  to 
take  the  drag  from  the  gastrohepatic  sutures. 


GASTRIC  OPERATIONS  91 

Gastrotomy. — Probably  the  most  frequent  cause  for 
surgical  interference  with  the  stomach  is  occasioned  by 
gastric  or  duodenal  ulcers.  These  ulcers  may  render  life 
unendurable  through  the  severe  pain,  or  endanger  it  by  pro- 
fuse hemorrhage  or  rupture,  and  the  escape  of  the  stomach 
contents  into  the  peritoneal  cavity.  Persistent  ulceration 
associated  with  nature's  efforts  at  repair  through  cicatriza- 
tion may  result  in  contraction  and  pyloric  obstruction.  The 
recognition  of  an  ulcer  of  the  stomach  does  not  necessarily 
demand  resort  to  surgery,  for  many  patients  under  a  care- 
fully directed  medical  regimen  recover,  but  in  numerous  in- 
stances delays  are  dangerous,  and  it  may  be  questioned 
whether  in  the  majority  of  instances  recovery  would  not  be 
expedited  by  early  surgical  interference. 

For  instruments  and  preparations,  see  Fig.  23. 

The  incision  has  been  made.  The  stomach  is  drawn  out 
and  carefully  examined.  The  ulcer  is  most  frequently  found 
near  the  pyloric  end  and  the  lesser  curvature,  although  it 
may  affect  the  greater  curvature,  the  anterior  or  posterior 
walls.  It  consequently  may  be  readily  accessible  or  be  so 
situated  that  the  stomach  has  to  be  opened  to  reach  it.  The 
procedure  is  known  as  ''gastrotomy."  The  operation  is  done 
for  exploration  of  the  stomach  where  a  hardness  or  indura- 
tion is  situated  upon  its  posterior  w\all,  to  explore  the  mucosa 
for  ulceration  where  there  is  a  history  of  hematemesis  with- 
out presenting  any  evidence  of  cicatrization,  and  for  the  pur- 
pose of  removing  foreign  bodies.  A  perforation  is  best 
treated  by  searing   its   surface  with   a  thermocautery  knife 


92  CARE  OF  GYNECOLOGIC  PATIENTS 

and  suturing  the  opening  with  a  double  row  of  sutures.  An 
accessible  ulcer  attended  with  induration  may  be  wisely 
made  a  perforation  with  the  cautery,  and  then  closed  as  in 
ordinary  perforation.  In  suturing  these  openings  the  first 
row  of  sutures  should  be  silk,  while  the  second  may  be  chromic 
catgut.  The  inaccessible  ulcer  requires  an  incision  of  the 
stomach  through  its  anterior  wall  which  may  be  longitudinal 
or  vertical.  Retractors  are  inserted  and  the  cavity  inspected. 
The  abdomen  is  carefully  protected  from  soiling  by  gauze 
packing.  An  ulcer  may  be  inverted  through  the  opening, 
be  cauterized  with  the  cautery,  and  sutured  from  within  with 
silk  sutures,  ensuring  the  contact  of  a  thick  layer  of  peritoneal 
surfaces.  The  gastric  incision,  is  then  closed  by  continuous 
or  interrupted  silk  sutures,  and  this  line  of  suture  covered 
by  a  row  of  chromic  catgut  suture  which  may  be  continuous. 
All  gauze  packing  is  effectually  removed  before  closing  the 
wound.  The  nurse  in  care  of  gauze  pads  must  keep  an  ac- 
count of  the  pads  used,  and  in  this  as  in  all  abdominal  pro- 
cedures be  certain  that  all  pads  used  are  in  sight. 

Gastro-enterostomy. — The  term  employed  for  a  com- 
munication between  the  stomach  and  the  small  intestine 
(Fig.  27).  It  may  be  called  a  gastroduodenostomy  when  the 
first  part  of  the  small  intestine,  or  a  gastrojejunostomy  when 
the  second  part  is  utilized. 

The  operation  may  be  an  anterior  or  posterior  gastro-enter- 
ostomy.    The  latter  is  the  one  most  frequently  preferred. 

Anterior  gastro-enterostomy  is  made  between  the  stomach 
and  the  jejunum.     A  coil  of  the  latter  has  its  contents  pressed 


GASTRIC  OPERATIONS  93 

out  and  is  grasped  by  one  of  the  clamp  forceps,  generally  with 
the  blades  covered  with  rubber.  The  other  pair  is  placed 
upon  a  fold  of  the  anterior  surface  of  the  stomach  near  its 
greater  curvature.  The  point  of  the  forceps  is  directed  across 
the  stomach  or  toward  its  lesser  curvature.  A  roll  of  gauze 
is  placed  between  the  two  pairs  of  forceps,  and  with  a  No.  i 
chromic  catgut  suture  the  long  diameter  of  the  intestine  is 
sutured  to  the  transverse  diameter  by  a  continuous  suture  for 


i 

■    '             y 

1 

i 

i 

i 
( 

! 

:                    / 

__^- 

/       *^ 

/ 

r\. 

\ 

V 

\ 

; 

\  '\ 

/ 

\ 

/ 

.. 

Fig.  27. — Gastroduodenostomy.     Kocher's  method.     (Keen's  "Surgery.") 

about  3  to  4  cm.  With  the  surfaces  carefully  protected  an 
incision  f  to  i  cm.  from  the  sutured  line  is  made  into  the 
stomach  and  intestine.  The  purpose  of  making  it  so  low  in  the 
former  is  to  make  sure  there  will  be  no  undrained  portion. 
The  raw  edges  of  stomach  and  intestine  are  united  with  a 
continuous  suture  of  silk  (Fig.  28),  which  should  interlock 
about  every  third  or  fourth  turn,  and  should  completely  en- 
circle the  opening.     When  the  opening  is  thus  closed  the  clamps 


94 


CARE  OF  CA'XECOLOGIC  PATIENTS 


may  be  removed  and  the  second  row  of  suture  (catgut)  be 
resumed  until  it  completely  covers  the  silk  suture.  As  these 
cases  sometimes  suffer  from  a  vicious  circle,  the  contents  of  the 
jejunum,  consisting  of  food  which  still  passes  the  pylorus,  the 
bile,  and  pancreatic  secretion,  enter  the  stomach  at  the  com- 


h  -~ 


a 


i. 

Fig.    28. — Anterior  gastrojejunostomy.     Showing   the   correct    position    (a)    and    the 
incorrect  position  (/))  for  the  anastomosis.     (Keen's  "Surgery.") 

munication  and  are  vomited,  this  condition  has  been  met  by 
making  an  anastomosis  between  the  surfaces  of  the  jejunum, 
so  that  the  contents  of  the  latter  will  not  reach  the  communi- 
cation with  the  stomach. 

Posterior  gastro-enterostomy  is  the  operation  of  preference, 
the  anterior  being  done  where  it  is  not  feasible  (Fig.  29).     The 


GASTRIC  OPERATIONS 


95 


latter  is  done  when  the  mesocolon  is  too  short  to  permit  carry- 
ing the  stomach  through  it,  or  the  posterior  wall  is  fixed  by 
adhesions  or  is  the  seat  of  cancer.  In  the  posterior  procedure 
the  colon  and  omentum  are  turned  upward,  an  opening  through 
the  mesocolon  avoiding   large  vessels,  and  a  portion  of  the 


Fig.  2g. — Posterior   gastro  enterostomy.    The   inner  suture  nearly  completed.     The 
mucosa  being  turned  outward,  not  inward  (Moynihan). 

posterior  wall  of  the  stomach  drawn  through  and  clamped. 
A  loop  of  the  jejunum  is  also  secured  with  another  clamp  in 
its  course  from  left  to  right. 

Mayo  emphasizes  the  importance  of  avoiding  a  reverse 
turn  in  uniting  the  intestine.  As  in  the  anterior  operation,  a 
pad  of  gauze  is  placed  behind  the  forceps,  the  peritoneal  sur- 


96  CARE  OF  GYNECOLOGIC  PATIENTS 

faces  sutured  with  chromic  catgut,  the  desired  length  being  3 
to  4  cm.,  an  incision  is  made  into  each  fold  while  the  abdomen 
is  carefully  protected  from  soiling.  The  edges  of  the  united 
flaps,  including  the  mucous  membrane,  are  sutured  by  con- 
tinuous silk  (No.  i)  suture,  and  this  suture  is  continued,  occa- 
sionally interlocking  it,  until  the  union  of  the  stomach  and  in- 
testine is  completed  by  closure  of  the  opening.  The  clamps 
are  removed  and  the  catgut  suture  resumed  and  continued, 
completing  the  second  line  of  suture.  The  opening  in  the  meso- 
colon is  closed  about  the  anastomosis.  Neglect  of  this  pre- 
caution has  occasioanally  led  to  a  hernia  of  the  small  intestine 
through  the  opening  and  to  a  serious  obstruction. 

Gastroduodenostomy  and  pyloroplasty  are  methods  employed 
in  pyloric  obstruction,  but  it  is  unnecessary  to  more  than  men- 
tion them  here,  as  they  do  not  require  additional  technic. 

Gastrogaslrostomy  may  be  employed  in  hour-glass  contrac- 
tion. 

Pyloredomy  and  partial  gastrectomy  are  required  in  gastric 
carcinoma,  when  the  disease  is  so  circumscribed  as  to  afford  a 
reasonable  probability  of  recovery,  or  rendering  more  com- 
fortable the  remaining  span  of  life  for  the  sufferer.  As  the 
supply  of  blood  to  the  stomach  comes  from  the  celiac  axis  the 
extent  of  the  structure  removed  will  depend  upon  the  vessel 
destruction.  The  field  involved  is  carefully  inspected  for  evi- 
dences of  transmission  to  the  lymphatic  nodes  in  this  region, 
and  when  such  have  occurred  the  advisability  of  a  radical 
operation  is  questionable.  The  gastric  branches  in  the  gastro- 
hepatic  and  large  omentum  are  tied  and  cut  through  the  length 


GALL-BLADDER  OPERATIONS  97 

of  the  proposed  resection.  The  wall  of  the  stomach  is  clamped 
by  the  stomach  forceps  well  external  to  the  disease,  while  a 
second  large  pair  of  forceps  is  appKed  close  to  the  disease  struc- 
ture, and  the  incision  with  scalpel  or  scissors  made  between 
them.  The  same  course  is  followed  upon  the  pyloric  side. 
The  surfaces  are  carefully  protected  by  gauze  from  soiling 
during  the  resection  and  the  surfaces  carefully  sponged  upon 
its  completion. 

The  operator  closes  the  open  surfaces  first  with  a  continu- 
ous silk  suture,  bringing  the  peritoneal  surface  in  contact,  and 
reinforces  this  with  a  suture  of  chromic  catgut  externally. 
Where  but  a  small  portion  of  the  stomach  has  been  resected,  an 
anastomosis  ma}-  be  made  between  the  lower  end  of  the  gastric 
incision  and  the  pylorus,  but  in  all  cases  where  the  tension 
would  be  great  the  wounds  should  be  closed  and  communica- 
tion established  between  the  most  dependent  portion  of  the 
stomach  and  the  jejunum. 

GALL-BLADDER   OPERATIONS 

Operations  on  the  gall-bladder  are  most  frequently  occa- 
sioned by  obstruction  of  the  bile  tracts  by  concretions  known 
as  gall-stones.  They  most  frequently  form  and  accumulate 
in  the  gall-bladder.  They  may  vary  in  number  from  one  to 
several  hundred,  and  in  size  from  the  calculus  as  large  as  the 
end  of  a  thumb  to  the  millet-seed  size  in  great  numbers.  They' 
may  be  rough,  strawberry-like,  or  perfectly  smooth  where  they 
attain  to  considerable  size,  and  where  many  are  packed  to- 
gether they  are  facetted.     They  may  exist  in  large  numbers  in 

7 


9S 


CARE  OF  GYNECOLOGIC  PATIENTS 


GALL-BLADDER  OPERATIONS  99 

the  gall-bladder  and  produce  no  characteristic  symptoms. 
The  patient  frequently  complains  of  a  sense  of  discomfort  and 
burning,  which  is  attributed  to  dyspepsia.  When  the  con- 
cretions enter  the  cystic  duct  in  their  course  toward  the  intes- 
tine the  patient  may  suffer  violent  attacks  of  colic  attended 
with  nausea  and  vomiting.  Where  the  calculus  passes  into 
the  common  or  hepatic  ducts,  not  only  does  the  patient  suffer 
severe  pain,  but  becomes  profoundly  jaundiced,  and  is  affected 
by  more  or  less  morbid  toxemia.  Infection  of  the  gall- 
bladder may  result  from  coli  bacillus,  the  bacillus  of  la  grippe, 
or  typhoid,  and  be  favored  by  the  continued  irritation  of  the 
gall-stones.  The  gall-bladder  may  be  thickened  and  con- 
tracted or  greatly  distended,  forming  a  large  sac,  the  walls  of 
which  are  fragile,  rupturing  in  the  efforts  at  separating  it,  or 
even  under  manipulation  prior  to  operation  for  purposes  of 
diagnosis. 

The  patient  prepared  for  abdominal  operation  is  placed 
upon  a  table  which  is  broken  so  that  the  chest  lies  above  the 
break.  This  position  can  be  accomplished  by  a  sand-bag  or 
inflated  rubber  bag  under  the  back.  The  incision  may  be 
made  in  the  median  hne,  parallel  with  the  ribs,  or  in  the  right 
semilunar  muscle,  S  shaped  as  suggested  by  Bevan,  as  the 
operator  may  prefer.  The  grid-iron  opening,  in  which  the 
various  muscles  are  split  and  held  apart,  may  be  utilized  where 
a  large  opening  will  not  be  required.  A  vertical  opening  will 
generally  be  most  satisfactory,  as  an  opportunity  is  afforded 
for  the  extension  of  the  incision  when  required.  The  abdomen 
opened,  the  self-retaining  retractor  is  placed,   the  intestine 


lOO 


CARE  OF  GYNECOLOGIC  PATIENTS 


walled  off,  and  the  condition  of  the  gall-bladder  and  its  rela- 
tions dctcnnined  by  sight  and  touch. 

The  exigencies  of  the  conditions  found  may  require  resort 
to  one  of  the  several  procedures.  Cholecystotomy  is  opening 
of  the  gall-bladder  for  the  evacuation  of  gall-stones  and  in- 
flammatory collections.  Such  an  opening  may  be  at  once 
closed.  In  cholecystostomy  the  opening  is  maintained  for  a 
length  of  time  for  drainage,  as  in  infections  of  the  gall-bladder 


Fig.  31. — Sectional  cut  showing  the  gall-bladder  and  tube  in  position.     (After  Binnie.) 

and  bile-ducts,  and  for  inflammation  of  the  pancreas  (Fig. 
31).  Cholecystectomy  is  done  when  the  changes  in  the  gall- 
bladder from  inflammation  and  gangrene  render  its  retention 
dangerous.  Choledochotomy  is  done  when  the  common  duct 
has  to  be  opened,  as  for  the  removal  of  impacted  gall-stone. 
Choledochostomy  when  this  opening  has  to  be  maintained  for 
a  length  of  time.  Choledochectomy  when  a  portion  of  the 
common  duct  has  to  be  removed.     The  condition  of  the  bile- 


G.\LL-BLADDER  OPERATIONS  lOI 

ducts  may  further  require  choledochoplasty,  as  for  the  closure 
of  a  biliary  fistula,  or  cholec}stogastrostomy,  cholecystoduod- 
enostomy,  cholecystojejunostomy,  cholecystoileostomy,  and 
cholecystocolostomy,  respectively  a  communication  between 
the  gall-bladder  and  stomach,  duodenum,  jejunum,  ileum,  or 
the  colon,  as  the  changes  of  the  structures  may  demand.  ^'  Ad- 
hesions of  the  omentum  and  intestines  to  itie  gall-bladder  arc 
carefully  separated  and  the  intestines  v/alled  off,  ffoni'tlie'iieid 
by  gauze  packing,  while  the  exposure  is  made  complete  by  re- 
tractors held  by  the  intern  or  nurse.  When  the  gall-bladder 
is  distended  it  can  be  draw^n  out  by  hemostats  and  cut  between 
them,  and  its  contents,  whether  bile,  pus,  or  calculi,  evacuated 
without  danger  of  soiling  the  peritoneal  cavity.  While  the 
intern  holds  the  opening,  the  operator  should  pass  his  hand 
along  the  common  and  hepatic  ducts  and  endeavor  to  coax  any 
calcuh  which  have  entered  them  back  into  the  gall-bladder  to 
secure  their  evacuation.  Where  the  gall-bladder  is  not  easily 
brought  u})  it  may  be  partially  separated  from  the  liver,  or 
where  this  is  not  sufficient,  the  abdomen  about  it  should  be 
packed  with  gauze  to  absorb  the  discharges  which  may  follow 
its  opening.  The  removal  of  small  stones  and  the  detritus  or 
sand  may  be  facilitated  by  syringing  out  the  tract  with  warm 
salt  solution.  The  removal  of  large  calculi,  or  those  impacted, 
may  be  facilitated  by  the  employment  of  the  scoop  or  forceps. 
The  impaction  of  a  large  stone  in  the  common  (kict  may  de- 
mand the  incision  of  the  duct  for  its  delivery.  The  operator 
should  never  neglect  to  make  certain  that  no  calculi  remain  in 
the  common  and  hepatic  ducts,  for  otherwise  relief  will  be  in- 


I02  CARE  OF  GYNECOLOGIC  PATIENTS 

complete  and  the  surgery  be  justly  censured.  Where  the  gall- 
stones have  been  completely  evacuated  and  the  gall-bladder 
shows  no  evidences  of  inflammation  and  thickening,  the  gall- 
bladder wound  can  be  closed  by  a  double  row  of  sutures.  In 
the  majority  of  cases  demanding  operation  it  will  be  advis- 
a-hle  yo  insert  d  d,rain^  a  section  of  ^-  to  |-inch  rubber  tubing  is 
inserted  into  the  bladder,  the  opening  sutured  about  it  with 
chromic  catgut,  :a,nd  the  latter  carried  into  the  tube  to  insure 
its  remaining.  Unless  there  has  been  extensive  perivesical 
inflammation  no  drainage  of  the  tube  will  be  required.  When 
the  calculus  has  required  the  incision  of  the  common  duct, 
accompanying  infection  or  contraction  may  demand  that  the 
common  duct  shall  be  drained,  o,r  the  condition  of  the  gall- 
bladder may  demand  the  removal  of  the  latter.  In  these  in- 
stances drainage  of  the  abdomen  may  likewise  be  required. 
The  drain  for  the  common  duct  should  be  a  right-angled  rubber 
tube,  constructed  in  one  piece,  sutured  into"  the  common  duct. 
The  abdomen  may  be  drained  by  a  separate  rubber  drain 
or  by  cigarette  drains  of  gauze  and  rubber  tissue,  or  the  field, 
when  there  have  been  extensive  adhesions,  may  be  walled  off 
by  sterile  or  iodoform  gauze  and  the  ends  brought  out  of 
the  wound  about  the  tube.  When  the  bladder  only  is  drained, 
the  tu1)c  may  be  lirought  out  through  the  wound,  or  when  more 
closely  related  to  the  peritoneal  surface,  through  a  stab  wound 
just  over  the  bladder.  It  is  unnecessary  to  suture  the  bladder 
to  the  peritoneum,  as  traction  on  the  tube  draws  it  into  the 
stab  wound.  Care  should  be  exercised  that  the  bladder  does 
not  come  next  the  skin  surface,  otherwise  the  continuity  of 


THE  SPLEEN  103 

mucosa  to  the  skin  prevents  the  closure  of  the  fistulous  tract. 
When  gauze  is  used  for  drainage  unenveloped  by  rubber  tissue 
it  should  be  left  for  five  or  seven  days  before  removal  or  until 
it  can  be  easily  withdrawn.  It  is  a  filthy  method  of  drainage 
and  is  followed  by  extensive  adhesions,  so  that  it  is  better 
avoided.  The  rubber  drain  after  the  wound  is  closed  may  be 
inserted  into  a  flat  bottle  buried  within  the  dressings,  or  be  con- 
nected with  another  tube,  the  end  of  which  is  carried  into  a 
bottle  suspended  froni  the  side  of  the  bed.  The  end  of  the 
tube  should  be  immersed  in  a  5  per  cent,  solution  of  carbolic 
acid  to  prevent  the  aspiration  of  germ-laden  air  into  the 
abdomen  through  the  tube.  Traction  on  the  tube  from  time 
to  time  after  the  end  of  a  week  will  soon  bring  about  its  with- 
drawal, when  the  sinus,  unless  the  canal  is  obstructed,  will 

promptly  close. 

THE    SPLEEN 

The  spleen  may  become  injured  by  falls,  blows,  or  stab 
wounds,  and  in  severe  cases  may  demand  its  removal.  The 
instances  in  which  the  removal  of  the  spleen  is  indicated  are 
infrecjuent.  In  addition  to  the  already  indicated  injuries,  the 
spleen  is  removed  for  malignant  disease,  marked  material  en- 
largement, splenic  enlargement,  and  when  the  organ  is  very 
movable  (Fig.  32). 

Operation.—  The  incision  Is  generally  made  in  the  median 
line,  although  in  large  tumors  the  incision  through  the  left 
semilunaris  may  afford  more  ready  access  to  the  pedicle,  and 
additional  room  may  be  secured  by  cutting  across  the  rectus. 
The  wound  opened  and  vessels  secured,  the  extent  of  adhesions 


I04 


CARE  OF  GYNECOLOGIC  PATIENTS 


should  determine  the  course,  those  to  the  diaphragm  and  pan- 


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creas  generally  affording  the  greatest  difficulty.     The  omental 
adhesions  may  be  separated  between  ligatures.     The  spleen 


OPERATIONS  UPON  THE  KIDNEY  105 

raised  and  carefully  delivered  through  the  wound.  Great 
care  must  be  exercised  that  the  friable  organ  is  not  torn.  Trac- 
tion upon  the  vessels  of  the  pedicle  may  cause  severe  shock. 
Where  they  are  not  securely  tied,  a  vessel  may  retract,  causing 
a  quickly  fatal  hemorrhage.  As  the  spleen  is  raised  and 
brought  out  of  the  wound,  the  intestines  are  packed  back 
with  gauze  to  keep  exposed  the  pedicle  of  the  spleen.  It  is 
very  important  to  make  certain  that  every  vessel  is  hgated,  and 
they  should  be  tied  with  No.  i  chromic  catgut,  but  not  so 
tight  as  to  endanger  cutting  through  the  vessels.  It  is  unwise 
to  tie  a  large  pedicle  in  mass,  for  the  retraction  of  a  vessel  is 
not  infrequently  attended  with  a  fatal  hemorrhage.  Where 
adhesions  are  broad  the  chain-interlocking  suture  should  be 
employed.  In  adhesion  to  the  pancreas,  the  removal  of  a 
portion  of  the  latter  may  be  necessary.  Wherever  possible, 
peritoneum  should  be  sutured  over  denuded  areas.  All 
gauze  packs  should  be  removed  and  the  wound  closed  without 
drainage  unless  extensive  areas  have  been  denuded,  when 
either  a  wick  or  gauze  packing  should  be  employed. 

OPERATIONS   UPON   THE   KIDNEY 

Surgical  relief  may  be  demanded  for  traumatic  or  dis- 
eased conditions  of  the  kidney.  The  latter  are  the  more 
frequent,  and  vary  from  mobility,  interfering  with  the  com- 
fort and  safety  of  the  patient,  to  extensive  destructive 
conditions  which  demand  incision  and  drainage  or  complete 
extirpation. 

The  position  of  the  incision  depends  upon  its  purpose.     In 


io6 


CARK  Ul'  GVNECOLUCJIC  TATIENTS 


all  procedures  for  disorders  unattended  by  marked  increase 
in  size  the  oblique  lumbar  incision  is  preferable  (Fig.  ^^). 


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A  table  with  an  arrangement  for  breaking  it.     Where  the 
latter  arrangement  is  not  present,  there  should  be  provided  sand 


OPERATIONS  UPON  THE  KIDNEY 


107 


pillows  or  a  rubber  cushion  (Edebohls).  The  patient  should 
lie  in  a  semiprone  position  on  the  left  side  where  the  right 
kidney  is  the  one  affected,  over  the  break  or  pads,  so  that  the 
ribs  and  crest  of  the  ileum  shall  be  widely  separated.  The 
field  after  previous  preparation  is  painted  with  3^  per  cent, 
iodin  solution  and  enveloped  with  sterile  sheets  and  towels  held 
in  place  by  towel  clips. 


Fig. 


34. — After  section  of  latissimus  dorsi.     Cross  showing  position  of  incision  of  the 
aponeurosis  of  the  transverse  muscle.     (Greene  and  Brooks.) 


An  oblique  incision  is  made  outward  and  downward,  from 
the  point  where  the  twelfth  rib  emerges  from  beneath  the 
erector  spinae  muscles  to  a  point  one  fingerbreadth  above  the 
crest  of  the  ileum.  This  incision  carried  through  skin,  super- 
ficial fascia,  and  latissimus  dorsi  (Fig.  34).  The  oblique  can  be 
drawn  forward  and  the  fascia  of  the  transversalis  cut,  thus  ex- 
posing the  fascia  directly  over  the  kidney.  The  ilio-inguinal 
and  the  iliohypogastric  should  be  pulled  aside;  where  this  is 


lo8  CARE  OF  GYNECOLOGIC  PATIENTS 

impossible,  the  nerves -should  be  cut  and  sutured  at  the  close  of 
the  operation.  I  have  seen  relaxation  of  the  abdominal 
muscles  of  the  affected  side  follow  the  operation  and  lead  to  the 
diagnosis  of  hernia.  This  relaxation  or  paralysis  is  due  to 
innervation  following  cutting  the  iliohypogastric  nerve. 

In  movable  kidney  the  incision  described  admits  anchoring 
of  the  kidney.  It  is  called  "nephropexy."  The  enveloping 
perineal  fat  is  opened,  the  kidney  separated  from  it,  and  the 
surrounding  structures,  especially  the  colon  and  peritoneum, 
by  blunt  dissection,  and  is  then  drawn  out  of  the  wound  by  a 
finger  thrust  beneath  the  kidney,  or  the  investing  fatty  capsule 
may  be  seized  with  a  hemostat  near  the  lower  pole  and  raised, 
when  the  organ  can  usually  be  easily  drawn  out.  Should  there 
be  difficulty,  a  pair  of  concave-bladed  fenestrated  forceps,  by 
which  the  organ  can  be  seized  and  drawn  up  without  danger  of 
injury  by  compression,  should  be  used.  There  should  be  no 
difficulty  in  the  delivery  of  a  freely  movable  kidney.  Thus 
delivered,  the  capsule  is  opened,  a  grooved  director  passed 
under  it,  and  the  capsule  divided  the  length  of  the  convex 
border.  It  is  then  pushed  forward  and  backward  toward  the 
kidney  pelvis,  exposing  about  one-half  the  kidney  surface. 
Two  sutures  are  introduced  in  the  folded  capsule  on  each  of 
the  anterior  and  posterior  surfaces,  parallel  to  the  long  axis  of 
the  kidney.  These  sutures  are  passed  through  the  muscle 
and  aponeurotic  layers,  but  not  through  the  skin,  and  tied. 
They  carry  the  kidney  into  the  incision.  The  muscle  and  fas- 
cia are  closed  with  chromic  catgut  sutures,  turning  the  raw  sur- 
face of  the  quadratus  lumborum  muscle  in  contact  with  the 


OPERATIONS  UPON  THE  KIDNEY 


109 


raw  kidney  surface.     The  skin  may  be  closed  by  a  continuous 
catgut  suture. 

Nephrotomy. — With  the  preparation  indicated,  and  through 
a  similar  incision,  the  kidney  may  be  opened  for  the  removal  of 


Fig.  35. — Opening  kidney  with  silver  wire.     (Ernest  K.  Cullen,  in  "Surg.,  Gyn.,  and 

Obst.") 

a  calculus,  the  evacuation  of  a  pus  collection,  or  the  exploration 
of  its  pelvis  and  calices.  The  kidney  maybe  opened,  extend- 
ing through  its  convex  border,  but  the  incision  with  a  knife  is 


no  CARE  OF  GYNECOLOGIC  PATIENTS 

often  attended  with  frightful  hemorrhage.  CuUen  and  Derge 
advocate  doing  nephrectomy  with  a  silver  wire  (Nos.  3  or  4). 
The  wire  is  threaded  into  a  long,  round -pointed  or  liver  needle, 
and  carried  the  distance  desired  for  the  opening  (Fig.  35). 
The  capsule  of  the  kidney  is  incised  over  the  desired  course;  the 
two  ends  of  the  wire  are  drawn  upon  by  a  sawing  motion  until 
the  opening  has  been  accomplished  and  without  much  bleeding. 
The  direction  of  the  incision  should  be  determined  by  the  dis- 
tribution of  the  vessels  and  its  purpose.  The  position  of  the 
renal  incision  for  the  removal  of  a  calculus  will  depend  upon  its 
size  and  situation.  If  it  occupies  the  caHces  of  the  kidney,  the 
incision  should  be  either  longitudinal  or  vertical.  If  it  is  situ- 
ated in  the  pelvis,  and  especially  when  small,  the  opening 
should  be  through  the  membranous  wall,  exercising  care  not  to 
injure  the  vessels.  Where  it  is  desirable  to  maintain  drainage, 
the  opening  in  the  kidney  may  be  sutured  to  the  abdominal 
wall,  thus  constituting  a  nephrostomy.  The  cavity  may  be 
packed  with  gauze  or  have  a  rubber  tube  sutured  in.  When 
the  opening  is  in  the  membranous  structure  of  the  pelvis 
the  drainage  should  consist  of  a  small  roll  of  rubber  tissue. 

Nephrectomy.  The  degeneration  may  be  so  extensive  as 
to  demand  the  removal  of  the  entire  kidney.  The  kidney  is 
brought  up  in  the  manner  described.  The  condition  demand- 
ing the  operation  may  be  revealed  by  the  incision  into  its 
structure.  Its  pedicle  is  exposed,  the  ureter  divided  between 
ligatures,  the  arteries  and  veins  either  ligated  or  clamped  and 
cut,  releasing  the  kidney.  If  the  vessels  have  been  clamped 
they  should  now  be  ligated,  and  preferably  after  isolation 


OPERATIONS  UPON  THE  KIDNEY 


III 


rather  than  en  masse.  The  cavity  is  carefully  inspected,  and 
then,  after  insertion  of  drainage  or  the  employment  of  gauze 
packing,  the  wound  is  partially  closed. 

For  Large  Renal  Tumors. — When  the  kidney  is  occupied  by 
growths  of  considerable  size,  or  is  greatly  enlarged  by  pus  col- 
lections and  accompanying  inflammatory  changes,  the  oblique 


II 


//,.■■.  y/ 


\ 


[[\\u 


Ulll     'II 


Fig.  j6. — Lumbar  iliac  incision  for  nephro-ureterectomy.     (Greene  and  Brooks,  after 

Pierre  Duval.) 


lumbar  incision  is  insufficient.  The  incision  may  extend  from 
the  lower  end  of  the  oblique  incision  described,  around  the 
crest  of  the  ileum,  and  downward  in  the  corresponding  flank 
to  the  edge  of  the  rectus  muscle.  This  incision  is  the  one 
usually  recommended  for  nephro-ureterectomy  (Fig.  36). 
The  majority  of  the  operations  for  removal  of  the  kidney 


112 


CARE  OF  GYNECOLOGIC  PATIENTS 


will  not  require  so  extensive  an  incision.  An  alternative  pro- 
cedure is  to  open  the  abdominal  wall  external  to  the  rectus 
muscle  corresponding  to  the  affected  side,  exposing  the  peri- 
toneum without  opening  it,  and  then  push  it  from  the  ab- 
dominal wall  outwardly  until  the  kidney  within  its  perineal 
fat  is  exposed  (Fig.  37).     If  the  surrounding  structures  are 


Fig.  37. — Abdominal  incision  for  removal  of  kidney.     (Hartmann.) 

not  too  extensively  involved  in  the  inflammation  or  infiltra- 
tion, it  may  be  completed  as  a  retroperitoneal  operation. 

In  the  majority  of  large  tumors  of  the  kidney,  whether  from 
inflammatory  or  neoplastic  changes,  the  mass  will  project  into 
the  abdominal  cavity,  and  so  ultimately  connect  with  the  en- 
veloping peritoneum  that  it  will  have  to  be  removed  with  the 
kidney.      In  the  latter  cases  the  condition  of  the  circulation  of 


OPERATIONS  UPON  THE  KIDNEY  113 

the  adjacent  portion  of  the  colon  must  be  determined.  When 
the  peritoneum  is  dissected  off  only  the  outer  surface  of  the 
colon  is  exposed  and  its  circulation  is  unaffected.  The  peri- 
toneum pushed  back  exposing  the  kidney,  the  intestine  is 
walled  back  with  gauze  and  retractors  are  employed  to  main- 
tain the  exposure.  The  kidney  is  separated  from  its  bed,  the 
ureter  is  exposed,  ligated  with  a  double  ligature,  and  cut  be- 


•l^g^^^ 

X^' 

L 

J 

1 

^ 

^^^a~V 

'/AvAyA^J^^^Ay^.-^-' 

^ 

P^ 

^/ 

-3- 

Fig.  38. — Nephrectomy.     (Greene  and  Brooks,  after  Berger  and  Hartmann.) 

tween  them.  The  vessels  are  isolated  if  possible  and  ligated 
separately  with  chromic  catgut,  and  upon  completion  of  the 
ligation  the  kidney  mass  is  removed  (Fig.  38).  If  the  ureter 
is  infected,  especially  with  tuberculous  disease,  it  should  be 
removed  throughout  its  entire  length.  The  retention  of  such  a 
focus  endangers  the  extension.  The  employment  of  the  pro- 
longed oblique  incision  affords  the  best  exposure.  The  dis- 
section should  be  accompanied  without  traction  on  the  ureter, 


114  CARE  OF  GYNECOLOGIC  PATIENTS 

for  where  thickened  by  inflammation  it  is  easily  broken  and  the 
spread  of  infection  is  thus  endangered  and  its  complete  removal 
rendered  difificult.  If  it  becomes  healthy  near  the  bladder,  a 
ligature  can  be  applied  and  the  ureter  cut  externally.  When 
the  disease  involves  the  lower  portion,  its  vesical  orihce  should 
be  excised  and  the  opening  closed  with  a  double  row  of  chromic 
catgut  sutures.  The  treatment  of  the  wound  will  be  con- 
sidered later. 

Where  it  has  been  necessary  to  open  the  peritoneum,  it 
should  be  closed  or  gauze  packing  should  be  employed,  to 
prevent  contact  of  the  peritoneal-covered  intestines  with 
the  raw  surfaces.  When  the  peritoneum  can  be  left  a  closed 
sac,  the  wound,  which  is  usuall}'  a  large  one,  should  be  drained 
with  a  series  of  spHt  rubber  tubes,  ropes  of  gauze  covered 
with  rubber  tissue,  or  iodoform  gauze  packed  in  the  pelvis. 
The  muscle  and  fascia  should  be  accurately  closed  with 
chromic  catgut  sutures  except  where  vents  for  drainage  are 
necessary.  In  dressing  the  wound  a  considerable  quantity 
of  gauze  should  be  applied  and  this  covered  with  pads  of 
cotton  and  gauze.  The  dressing  should  be  changed  as  soon 
as  there  is  an  indication  of  its  being  soiled.  Saturated 
dressings  should  not  be  allowed  to  remain,  as  they  afford 
ready  entrance  for  infection. 


VAGINAL    OPERATIONS 

After  the  removal  of  the  hair  from  the  lower  abdomen 
and  a  hot  bath,  the  nurse  washes  the  abdomen  and  genitalia 
with  soap  and  hot  water  and  administers  a  vaginal  douche  of 
a  solution  of  mercuric  bichlorid  (i  :  2000)  or  iodin  (Lugol's 
solution,  I  dram  to  i  quart  of  hot  water).  These  douches 
should  be  given  three  times  in  the  twenty-four  hours  preced- 
ing operation,  and  in  the  intervals  the  vulva  kept  covered 
with  a  sterile  gauze  pad.  When  the  patient  comes  to  the 
table  for  operation  she  should  have  the  vagina  and  the  ex- 
ternal parts,  including  the  buttocks  and  the  inner  surface  of 
the  thighs,  thoroughly  scrubbed  with  tincture  of  green  soap 
and  hot  water.  For  this  purpose  the  fingers  should  be 
wrapped  with  sterile  gauze.  The  superfluous  soap  should  be 
washed  away  with  hot  sterile  water,  and,  fmalh',  the  parts 
scrubbed  with  a  50  per  cent,  alcohol  solution,  dried,  and 
painted  with  3.5  per  cent,  solution  of  iodin.  The  patient  is 
placed  on  her  back,  with  legs  flexed  and  supported  by  leg- 
holders.  The  feet  and  legs  are  covered  with  sterile  dressings 
and  the  vulva  isolated  with  sterile  towels,  which  should  be 
held  in  place  by  towel  clips. 

The  principal  operations  done  on,  or  through,  the  vagina 
are  dilatation  and  curetment,  excision  of  growths,  plastic 
operations  on  the  anterior  and  posterior  \aginal  walls,  repair 

"5 


ii6  CARE  OF  GYNECOLOGIC  PATIENTS 

of  the  cervical  canal,  known  as  "trachelorrhaphy,"  ampu- 
tation of  the  cervLx,  closure  of  the  fistulous  openings  be- 
tween the  vagina  and  bladder,  or  the  vagina  and  rectum,  and 
hysterectomy. 

DILATATION   AND    CURETMENT 

The  patient  has  been  prepared  as  directed  for  vaginal 
operations,  the  perineum  retracted  and  held  back  by  a 
weighted  speculum;  two  tenacula  are  inserted  in  the  anterior 
lip  and  held  with  the  left  hand  of  the  operator. _  The  direc- 
tion of  the  canal  having  been  previously  determined  by  care- 
ful bimanual  examination,  the  graduated  bougies,  of  which 
there  are  two  on  each  central  handle,  are  introduced,  begin- 
ning with  the  smaller  size,  one  after  another,  until  the  de- 
sired dilatation  has  been  accompUshed  (Fig.  40).  The  in- 
tern hands  the  bougies,  with  the  smaller  instrument  directed 
toward  the  cervix.  The  nurse  connects  the  curet  to  the 
douche-bag  and  is  ready  to  open  it  as  soon  as  the  dilatation 
is  completed.  The  douche  fluid  washes  away  the  scrapings 
and  mucus  as  the  instrument  is  carried  by  long  sweeps  over 
the  anterior,  posterior,  and  lateral  walls  of  the  uterine  cavity, 
and  is  finally  carried  across  the  fundus  from  one  opening  of 
the  fallopian  tube  to  the  other.  The  nurse  has  ready  a 
small  pledget  of  sterile  absorbent  cotton  which  she  has  satu- 
rated with  iodoform  solution,  and  the  operator  carries  this 
to  the  fundus,  and  as  it  is  withdrawn  the  contents  are  squeezed 
off,  the  ether  evaporates  with  the  temperature  of  the  body 
and   leaves  a   coating  of  iodoform.     In  some  instances  the 


DILATATION  AND   CURETMENT  I17 

cervical  glands  are  filled  with  secretion  and  have  been  con- 


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ii8 


CARE  OF  GYNECOLOGIC  PATIENTS 


with  tincture  of  iodin  to  set  up  sufficient  inflammation  to 
obliterate  the  cavity.  When  the  cureting  follows  an  abortion 
the  bleeding  may  be  free,  and  it  is  then  better  to  swab  the 
uterine  cavity  with  an  iodin  solution  and  pack  it  with  iodo- 


Fig.  40. — Dilatation  of  cervix  by  graduated  bougies. 


form  gauze.  In  recent  uterine  inflammation,  or  following  an 
abortion,  or  at  the  site  of  a  flexion  the  wall  of  the  uterus  may 
be  softened  and  be  readily  perforated  by  the  bougie.  This 
accident  does  not  necessitate  opening  the  abdomen,  but  the 
curet  should  be  used  without  the  douche  and  no  irritant  medi- 


TRACHELORRHAPHY  119 

cation  be  made  to  the  canal.  The  uterus  should  be  packed 
with  gauze  and  care  should  be  exercised  that  it  does  not 
project  through  the  perforation. 

TRACHELORRHAPHY 

This  is  the  designation  given  to  the  operation  designed 
by  Emmet  for  the  various  lacerations  of  the  cervix. 

The  patient  is  brought  to  the  end  of  the  operating-table, 
with  her  feet  supported  in  leg-holders  and  enveloped  in  sterile 
coverings.  The  vulva  is  isolated  with  sterile  sheets  and 
towels  held  in  place  with  towel  clips.  The  vagina  has  been 
cleansed  as  in  all  vaginal  operations,  and  the  cervix  is  exposed 
by  the  weighted  speculum.  The  intern,  standing  to  the 
right  of  the  operator,  who  sits  at  the  foot  of  the  table,  holds 
with  his  right  hand  a  double  tenaculum  in  the  anterior  lip, 
and  wdth  his  left  makes  traction  when  necessary  upon  the 
speculum.  A  nurse  to  the  right,  with  her  left  hand  holds 
a  tenaculum  placed  in  the  posterior  lip,  and  with  her  right 
mops  the  blood  from  the  field  of  operation.  The  denuda- 
tion may  be  made  on  one  or  both  sides,  according  to  the  ex- 
tent and  character  of  the  laceration.  Even  in  bilateral  lacer- 
ation, unless  the  tears  be  deep,  it  is  better  for  the  future  drain- 
age of  the  canal  that  the  repair  be  limited  to  one  side,  espe- 
cially to  the  side  in  which  it  has  been  most  extensive.  Where 
the  repair  is  to  be  confined  to  one  side,  the  cervix  should  be 
drawn  to  the  opposite  side,  and  if  deep  and  the  uterus  fixed, 
it  may  be  necessary  to  employ  a  lateral  retractor  to  expose 
the  apex  of  the  tear.     If  it  is  decided  to  confine  the  denuda- 


I20 


CARE  OF  GYNECOLOGIC  PATIENTS 


tion  to  the  right  side  ot  the  cervix,  the  assistants  should 


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reverse   their  hands   in   holding   the   tcnacula.     The   uterus 
should  always  be  cure  ted  as  a  preliminary  to  the  operation. 


TRACHELORRHAPHY 


121 


Beginning  on  the  posterior  lip,  the  operator  seizes  the  tissue 
near  the  point  for  the  new  os  and  outHnes  the  portion  to  be 
removed  by  an  incision  from  the  inside  of  the  canal  and 
another  on  the  vaginal  side  (Fig.  42).  The  tissue  or  flap 
thus  outHned  is  Ufted  toward  the  apex  of  the  tear  and  left  in 
position  while  the  denudation  on  the  anterior  lip  is  followed 
in  the  same  manner.  When  the  operation  is  bilateral  a 
similar  course  is  pursued  on  the  other  side  of  the  cervix,  tak- 


Fig.  42. — Denudation  for  trachelor- 
rhaphy. (Montgomery,  "Practical  Ciy- 
necology.") 


Fig.  43. — Bilateral  laceration  of  the 
cervi.x  and  sutures  introduced  for  union 
of  denuded  surfaces.  (Montgomerj', 
"Practical  Gynecology.") 


ing  care  to  preserve  a  central  undenuded  portion  on  each  lip 
for  the  future  cervical  canal.  The  denudation  completed 
(Fig.  43),  the  nurse  hands  a  needle  threaded  with  No.  i  chromic 
catgut,  and  the  first  suture  is  introduced  from  the  vaginal 
side  of  the  anterior  right  lip  of  the  cervix,  and  brought  out 
on  its  inner  surface  within  the  denudation  at  the  margin  of 
the  cervical  membrane;  the  left  suture  is  introduced  from  the 
posterior  lip  and  brought  out  on  the  anterior.     These  sutures 


122  CARE  OF  GYNECOLOGIC  PATIENTS 

are  situated  on  cither  side  of  the  new  os  and  temporarily 
secured  with  forceps;  the  tenacula  are  removed,  and  these 
sutures  are  used  as  retractors.  Their  introduction  and  em- 
ployment thus  ensures  the  union  of  the  lips  at  a  uniform 
length,  otherwise  it  would  be  difiicult  to  ensure  their  being 
properly  brought  together.  The  other  sutures  are  intro- 
duced on  either  side  to  ensure  the  proper  coaptation  of  the 
lips,  each  suture  being  carried  to  the  margin  of  the  cervical 
flap,  but  none  entering  it.     A  suture  entering  the  cervical 


Fig.  44. — Wound  closed.     (Montgomery,  "Practical  Gynecology.") 

mucosa  i)rejudices  the  result  in  two  ways:  first,  by  approxi- 
mating the  two  mucous  surfaces  it  diminishes  the  surface  for 
union;  and,  second,  its  presence  acts  as  a  seton  which  may 
result  in  a  cervicovaginal  fistula,  an  abnormal  opening  which 
will  be  a  source  of  annoyance  subsequently.  The  sutures 
in  place,  the  surfaces  are  separated,  all  blood-clots  removed, 
and  the  sutures  tied  without  undue  pressure,  just  securely 
enough  to  ensure  proper  apposition  (Fig.  44).  If  tied  1  irmly 
the  included  tissue  will  slough  out  and  the  laceration  recur, 


AMPUTATION  OF  THE  CERVIX  123 

or  the  increased  cicatricial  tissue  will  be  a  source  of  irritation. 
The  nurse  hands  a  section  of  iodoform  gauze,  about  4  inches 
long,  cut  from  a  fold  of  yard-wide  roll,  and  this  is  packed 
against  the  cervix. 

AMPUTATION   OF   THE    CERVIX 

The  cervix  is  amputated  when  the  laceration  has  existed 
for  some  time,  is  accompanied  by  hypertrophy,  eversion  of 
the  mucous  membrane,  or  glandular  degeneration  and 
erosion. 

The  patient  prepared  for  a  vaginal  operation  and  the 
vulva  isolated  with  sterile  dressings,  the  perineum  is  re- 
tracted with  a  weighted  speculum  (Fig.  46).  The  cervLx, 
after  the  uterus  is  cureted,  is  held  by  a  tenaculum  in  each 
lip,  and  with  a  scalpel  the  operator  encircles  the  opening  of 
the  cervical  canal,  cutting  through  the  mucosa  and  part  of 
the  muscular  laver.  The  tenaculum  is  removed  from  the 
posterior  lip,  and  wath  tissue  forceps  the  surgeon  holds  it 
while  with  the  knife  he  outlines  and  removes  a  flap  extend- 
ing from  one  side  of  the  cervix  to  the  other,  following  the 
junction  of  the  cervical  and  vaginal  mucosa.  He  then  re- 
moves the  tenaculum  from  the  anterior  lip,  and,  after  plac- 
ing it  on  the  posterior,  has  it  held  by  the  intern  while  he  fol- 
lows the  same  course  in  removing  a  flap  from  the  anterior 
lip.  In  both  instances  the  denudation  is  at  the  expense  of 
the  internal  surface.  The  removed  tissue  should  include  all 
eroded  and  diseased  structures  unless  the  ]:)Osterior  lip  is  too 
extensively  eroded  (Fig.  47).     The  important  consideration 


124 


CARE  OF  GYNECOLOGIC  PATIENTS 


is  to  secure  an  unconstricted  canal  for  uterine  drainage.     The 


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AMPUTATION  OF  THE  CERVIX 


125 


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Fig.  47. — Amputation  completed.     Surfaces  ready  for  suture.     ("Keen's  Surgery.") 


126 


CARE  OF  GYNECOLOGIC  PATIENTS 


or  three  sutures  anteriorly  and  posteriorly,  but  a  better 
method  is  to  employ  the  Bonney  method  of  suturing,  which 
consists  in  parsing  a  suture  in  the  center  of  the  vaginal  mucosa 
in  front,  tying  a  knot,  cutting  one  end  short,  and  then  insert- 
ing the  point  of  the  needle  into  the  cervical  canal,  bringing  it 


Fig.  48. — Bonney  suture. 


through  the  anterior  wall  and  securing  it  temporarily  with  a 
hemostat;  the  posterior  flap  is  treated  similarly  (Fig.  48). 
Traction  on  these  sutures  inverts  the  vaginal  surfaces.  A 
lateral  suture  is  inserted  on  cither  side  and  tied.  The  ante- 
rior suture  is  then  tied  to  the  ends  of  the  suture  on  the  pa- 


MIPUTATION  OF  THE   CERVIX 


127 


tient's  right,  while  the  posterior  is  secured  to  those  on  the 
left.  These  ends  are  then  secured  with  a  hemostat  and 
pulled  to  the  right  or  left  until  sutures  have  been  introduced 
to  hold  the  cut  surfaces  in  union  when  the  ends  are  cut.     By 


Fig.  40. — Sutures  in  place  and  wounti  closed. 

this  method  the  vaginal  surfaces  are  smoothly  iaverted  and 
there  is  no  suture  to  mar  the  external  appearance  of  the  os 
(Fig.  49).  The  blood  is  sponged  away,  the  surface  of  the 
wound  painted  with  dilute  iodin  solution,  and  a  compress  of 
iodoform  gauze  inserted. 


128  CARE  OF  GYNECOLOGIC  PATIENTS 

ANTERIOR   COLPORRHAPHY 

This  procedure  is  indicated  for  sagging  or  prolapse  of  the 
anterior  vaginal  wall,  and  is  usually  a  part  of  the  measure 
employed  to  correct  prolapsus  of  the  uterus.  This  opera- 
tion may  or  may  not  be  preceded  by  curetment  of  the 
uterus  and  amputation  of  the  cervix.  When  the  latter  has 
not  been  done,  the  cervix  is  seized  with  two  double  tenacula, 
which  are  held  by  the  intern  standing  to  the  left  of  the  opera- 
tor. The  latter,  sitting  at  the  end  of  the  table,  picks  up  the 
vaginal  mucosa  just  above  the  cervix  with  tissue  forceps,  and 
divides  the  vaginal  wall  in  the  median  line  to  the  base  of  the 
urethra,  or  even  near  the  external  meatus.  Each  side  is 
held  with  tissue  forceps  and  the  connective  tissue  is  opened 
with  scissors.  The  Bland  forceps  are  applied  to  the  vaginal 
wall  on  each  side  of  the  incision,  those  on  the  left  held  by  the 
intern  and  on  the  right  by  the  nurse,  when  the  operator 
separates  the  bladder  from  the  vaginal  flaps  by  blunt  dis- 
section to  the  extent  required  for  the  contraction  of  the 
vagina.  The  bladder  is  pushed  back  from  the  cervix  in  the 
same  manner.  Occasionally  it  may  be  necessary  to  cut 
through  the  connective  tissue  to  start  the  separation  from 
the  cervix.  When  an  amputation  of  the  cervix  is  done  it 
is  better  that  the  excision  of  the  vaginal  wall  should  pre- 
cede the  suturing  of  the  cervical  flaps.  Tn  hypertrophic 
elongation  of  the  cervix  it  may  be  desirable  to  remove  a 
considerable  portion  of  the  cervix,  and  the  previous  sutur- 
ing would  but  handicap  the  second  procedure.  In  these 
cases  it  may_be  desirable  to  anchor  up  the  cervix,  which  can 


ANTERIOR   COLPORRHAPHY 


129 


be  done  by  cutting  through  the  base  of  each  broad  liga- 


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9 


130  CARE  OF  GYNECOLOGIC  PATIENTS 

together  by  a  stitch  at  the  side  of  the  cervix,  one  end  of  which 
is  cut  short  and  the  other  carried  through  the  anterior  wall 
of  the  cervix,  as  in  the  Eonney  suture,  already  described. 
In  the  ordinary  operation  the  bladder  is  anchored  at  a  higher 
level  on  the  anterior  surface  of  the  cervix  by  two  or  more 
sutures  taken  in  the  connective  tissue  of  the  bladder  at  the 
base,  which  when  tied  folds  its  wall.  The  redundant  por- 
tion of  the  vaginal  flaps  are  removed  by  a  curved  incision  on 
either  side  and  the  vaginal  walls  united  by  interrupted 
chromic  catgut  sutures.  The  first  suture  is  placed  near  the 
cervix  and  the  others  in  succession  below  until  the  anterior 
wall  is  closed.  These  sutures  may  be  tied  as  they  are  intro- 
duced. The  surface  is  cleansed  with  an  alcohol  solution 
(50  per  cent.)  and  the  edges  of  the  wound  painted  with 
iodin  solution  (3.5  per  cent.),  dried,  and  if  the  procedure  com- 
pletes the  series  of  operation,  a  pledget  of  iodoform  gauze  is 
placed  against  the  cervix. 

VESICOVAGINAL  INTERPOSITION  OF  THE  UTERUS;  WATKINS' 

OPERATION 

The  preparations  and  instruments  designated  in  the 
preceding  operation  are  sufficient.  The  initial  method  of 
procedure  is  the  same.  The  cervix  should  be  amputated 
where  it  is  long,  large,  or  ulcerated.  Where  it  is  inclined 
to  sag  down,  the  lower  part  of  the  broad  ligaments  should  be 
cut  and  secured  in  front  of  the  cervix.  The  vaginal  incision 
is  made  as  in  the  procedure  of  anterior  colporrhaphy,  but 
the  bladder  is  pushed  off  from  the  anterior  surface  of  the 


VESICOVAGINAL  INTERPOSITION  OF  THE  UTERUS       131 

broad  ligament,  the  peritoneum  opened,  and  the  fundus 
brought  through  the  o})ening.  The  vesical  peritoneum  is 
secured  by  several  sutures  to  the  posterior  surface  of  the 


Fig.  51. — Vesicovaginal  interposition  of  the  uterus  (Watkins'  operation). 

uterus;  two  sutures  are  passed  through  the  left  side  of  the 
vaginal  incision,  through  the  anterior  surface  of  the  fundus, 
and  brought  out  through  the  right  side  of  the  vaginal  wall 
at  the  level  of  introduction  (Fig.  51).     These  sutures  lift  the 


132  CARE  OF  GYNECOLOGIC  PATIENTS 

fundus  under  the  base  of  the  bladder  and  upper  part  of  the 
urethra.  It  is  important  that  the  sutures  are  properly- 
placed,  otherwise  a  small  sac  forms  m  which  the  urine  will 
collect  and  cause  dribbhng  and  want  of  complete  control. 
The  superfluous  portion  of  the  vaginal  flaps  are  now  cut 
away,  retaining  sufficient  to  cover  without  tension  of  the  sur- 
face of  the  uterus.  The  sutures  are  introduced  transversely, 
securing  with  each  a  portion  of  the  anterior  uterine  wall. 
The  operation  completed,  the  uterus  lies  between  the  vagina 
and  bladder,  rendering  a  recurrence  of  the  protrusion  of  the 
bladder  impossible.  The  subsequent  cleansing  and  packing 
of  the  vagina  is  followed  as  in  the  previous  operation. 

VAGINAL   HYSTERECTOMY 

Removal  of  the  uterus  through  the  vagina  may  be  done 
for  cancer,  either  of  the  body  or  cervix,  when  "the  abdominal 
walls  are  very  thick  and  fat;  for  fibroid  growths  of  moderate 
size,  where  the  vagina  is  roomy;  for  prolapsus  with  lacera- 
tion of  the  cervix  or  ulceration  of  the  vaginal  walls.  It 
should  not  be  elected  for  cancer  \\'hen  the  condition  is  favor- 
able for  abdominal  section,  as  the  latter  affords  better  oppor- 
tunity of  getting  well  beyond  the  disease,  nor  for  fibroids  of 
a  size  that  will  make  them  difficult  of  delivery  (Figs.  52,  53). 

The  patient  is  prepared  for  vaginal  operation  with  the 
vulva  isolated  by  sterile  sheets  and  towels.  The  latter 
secured  by  clips  to  the  skin,  and  if  the  clip  is  in  the  way  at  the 
vulva  the  towel  can  be  secured  by  a  stitch  to  the  perineum. 
The  cervix  is  exposed  with  the  speculum  and  drawn  down  by 


VAGINAL  HYSTERECTOMY 


133 


a  double  tenaculum.     A  number  of  tenacula  are  applied  to 
the  cervix  in  such  a  manner  as  to  close  the  os  and  thus  prevent" 


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the  soiling  of  the  vagina  and  the  wound  with  the  secretions 
or  discharges.     The  instruments  thus  applied  serve  as  trac- 


134 


CARE  OF  GYNECOLOGIC  PATIENTS 


tors,  and  if  necessary  the  assistant  on  each  side  can  still 
further  aid  in  the  exposure  by  the  use  of  a  vaginal  retractor. 
The  operator,  holding  the  cervix  with  the  tenacula,  sweeps 
around  it  with  the  scalpel,  severing  it  from  the  vagina,  and 
then  with  a  gauze-wrapped  finger  pushes  the  vagina  and 
bladder  back  in  front  and  the  vagina  laterally  and  posteriorly. 


Fig.  53- — Procidentia  with  gravity  sores  on  the  cervix. 

The  nurse  hands  the  surgeon  a  needle  in  grasp  of  needle- 
holder,  threaded  with  No.  i  chromic  catgut;  while  the  in- 
tern holds  the  cervix  firm  witli  the  fixation  forceps  he  passes 
the  ligature  from  above  downward  against  the  finger  which 
has  been  placed  beneath  the  under  side  of  the  lower  part  of 
the  broad  ligament,  and  when  tied  this  ligature  secures  the 
uterine  artery  of  that  side.     The  vessel  of  the  other  side  is 


VAGINAL  HYSTERECTOMY  135 

secured  in  the  same  way,  and  when  the  tissue  is  cut  between 
the  ligature  and  cervix  the  organ  is  easily  brought  to  a  lower 
level.  If  the  vesico-uterine  fold  of  the  peritoneum  has  not 
already  been  opened,  it  should  be  now,  and  the  fundus  brought 
down,  the  carrier  again  threaded,  the  upper  portion  of  each 
ligament  is  tied,  and  before  cutting  is  secured  by  a  strong 
hemostat.  The  ligatures  are  cut  short  to  prevent  any  possi- 
bihty  of  being  pulled  on,  and  thus  possibly  permit  the  retrac- 
tion of  a  vessel  which  would  be  difficult  to  again  secure. 
The  uterus  is  cut  away  from  the  remaining  tissue,  the  in- 
tern being  ready  with  a  hemostat  to  secure  any  spurting 
vessels.  The  uterus  removed,  careful  inspection  is  made  for 
any  bleeding  vessels,  and  Ugatures  substituted  for  clamps 
except  the  two  on  the  upper  portions  of  the  ligaments.  The 
assistant  on  either  side  draws  upon  the  broad  ligament  with 
the  forceps,  while  the  operator  applies  another  hemostat  to 
the  peritoneum  covering  the  bladder,  a  suture  is  passed 
through  the  inner  (which  is  the  upper)  surface  of  the  left 
broad  ligament,  then  gathers  up  the  peritoneum  of  the  lower 
margin  of  the  bladder  and  carries  the  needle  downward 
through  the  upper  surface  of  the  right  ligament  (Fig.  54). 
A  second  suture  is  carried  backward  through  the  left  liga- 
ment, gathers  up  the  peritoneum  of  the  posterior  vaginal 
wall,  and  passes  forward  in  the  right  ligament.  These  two 
sutures  when  tied  close  the  peritoneum  from  the  vagina  and 
ensure  that  any  bleeding  occurring  shall  be  outside  the  ab- 
dominal cavity.  A  third  suture,  carried  from  the  left  ligament, 
picks    up    the    bladder  wall  near    its  base,  and  backward, 


136 


CARE  OF  GYNECOLOGIC  PATIENTS 


through  the  right  ligament  tied,  supports  the  bladder  on  the 
ligaments.  The  stumps  are  then  sutured  so  that  the  end 
of  one  overlaps  the  other,  and  the  ligaments  are  made  to  sup- 
port the  bladder  and  rectum.  The  vault  of  the  vagina  is 
exposed  by  a  retractor   held  by  the  intern  beneath  the  sym- 


Fig.  54. — Uterus  removed  and  sutures  introduced  for  closing  the  peritoneum. 

physis,  and  the  surgeon  sutures  the  lateral  points  of  the 
vaginal  vault  to  the  ligamental  stump  and  closes  the  upper 
part  of  the  vagina  by  anteroposterior  sutures.  The  raw 
surface  on  the  anterior  wall,  made  by  excision  of  the  pro- 
truding va^^ina,  is  closed  by  transverse  sutures,  which  pick 


VAGINAL  HYSTERECTOMY  137 

up  also  the  vesical  wall,  and  this  portion  is  closed  in  a  vertical 
line  with  interrupted  chromic  catgut  sutures  (Fig.  55).  The 
method  of  closing  here  described  is  particularly  applicable 
to  the  cases  in  which  the  operation  has  been  done  for  pro- 
lapsus, and  presupposes  that  a  flap  has  been  removed  from 


Fig-  55- — Sutures  introduced  closing  the  vagina. 

the  anterior  vaginal  wall  in  the  separation  of  the  vagina  from 
the  cervix. 

In  cases  in  which  the  vagina  is  not  so  distorted,  the  stump 
of  each  broad  ligament  may  be  secured  outside  the  peritoneum 
by  passing  a  purse-string  suture  through  the  anterior  and 
posterior  peritoneal  folds  around  the  one  stump  and  tying 


138  CARE  OF  GYNECOLOGIC  I'ATIENTS 

it  over  the  other.  This  ligation  secures  against  hemorrhage. 
The  vaginal  surfaces  should  then  be  united  by  interrupted 
catgut  sutures.  The  operation  thus  performed  leaves  no 
raw  surface  within  the  peritoneal  cavity  nor  within  the 
vagina,  and  the  recovery  is  rapid.  The  vagina  is  sponged 
free  of  blood,  the  hne  of  incision  painted  with  the  diluted 
iodin,  and  a  pledget  of  iodoform  gauze  packed  against  the 
vault.  The  packing  holds  the  vault  at  a  higher  level,  allows 
the  ligaments  to  contract,  and  by  cicatrization  ensures  a 
longer  and  more  fixed  vagina. 

PERINEORRHAPHY;      POSTERIOR      COLPORRHAPHY;     RECTO- 
VAGINAL   INTERPOSITION    OF   THE   LEVATOR  ANI   MUSCLES 

This  procedure  is  generally  supplementary  to  other 
operations.  It  is  rare  that  the  surgeon  would  confine  the 
procedure  to  the  perineum  only.  It  may  terminate  repair 
operations  on  the  cervix,  and  particularly  should  follow  ante- 
rior colporrhaphy  and  the  removal  of  the  uterus  for  prolap- 
sus. The  procedure  may  be  required  for  relaxation  of  the 
floor  or  for  extensive  laceration  through  the  sphincter  and  the 
rectovaginal  septum.  The  procedure  then  involves  not  only 
the  support  afforded  by  the  pelvic  floor,  but  also  the  restora- 
tion of  the  control  of  the  contents  of  the  intestine,  whether 
liquid  or  gas. 

The  preparation  of  the  patient  will  depend  upon  the  ex- 
tent and  purpose  of  the  operation.  The  bowel  should  be 
always  effectually  evacuated,  especially  when  laceration  ex- 
tends  through   or   into  the   sphincter.     The  patient  should 


PERINEORRHAPHY;   POSTERIOR  COLPORRHx\PHY         139 

have  been  restricted  in  her  diet  to  food  with  little  waste 
material,   as  meat  broths,   and  should  not   take   any   milk 


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after    the   purgative   has   been    administered.     The   evening 
preceding  the  operation  she  should  be  given   an  enema  of 


I40  CARE  OF  GYNECOLOGIC  PATIENTS 

soapsuds  and  the  vulvar  hair  should  be  removed  as  well  as 
that  about  the  anus.  This  is  best  done  with  a  dej^ilatory, 
as  thus  any  possibihty  of  injury  and  infection  of  the  skin  is 
avoided.  When  the  operation  is  done  for  relaxation  and 
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Fig.  57- — Incomplete  laceration  of  the  perineum. 


effectual  support,  the  vulva  is  separated  by  the  employment 
of  the  Bland  retractor  (Fig.  57).  This  instrument  has  two 
blades,  separated  by  a  spring  with  a  tenaculum  point  pro- 
jecting from  each  blade.  The  instrument  is  introduced  into 
the  vulva,  with  the  ])lades  closed,  and  placed  with  a  i:)oint 
against  the  remains  of  the  hymen,  known  as  the  caruncula, 


PERINEORRHAPHY;  POSTERIOR  COLPORRHAPHY         141 

on  either  side  the  vulva,  and  the  pressure  released  when  the 
vulva  and  orifice  of  the  vagina  is  widely  separated.  A 
double  tenaculum  picking  up  the  summit  of  the  vaginal 
eversion,  the  outlines  of  the  denudation  are  indicated.  The 
action  of  the  instrument  lifts  the  vaginal  wall  away  from 
the  rectum,  and  an  incision  can  be  easily  made  from  the 
tenaculum  above  to  the  margin  of  the  commissure  posterior 
and  carried  outward  to  the  end  of  the  retractor  on  either 
side,  which  outlines  flaps  for  excision  that  can  be  quickly 
Hfted  with  the  scalpel  and  removed.  This  dissection  exposes 
the  rectum  above  and  the  muscular  layer  below,  while  on 
either  side  can  be  exposed  the  edges  of  the  separated  levator 
ani  muscles.  With  a  curved  needle  armed  with  No.  i  chromic 
catgut  suture,  held  in  a  needle-holder,  the  surgeon  lifts  the 
edge  of  the  vaginal  wall  on  the  left  s  de,  passes  the  needle 
through  the  belly  of  the  levator  ani,  carries  it  downward 
through  the  fascia  covering  the  rectum,  upward  on  the  other 
side,  beneath  the  levator  ani,  and  clamps  the  ends  of  this 
suture  with  a  hemostat.  Traction  on  this  suture  lifts  up 
the  levator  ani  and  renders  the  subsequent  sutures  more 
easily  placed.  Three  sutures  are  generally  sufficient  to 
ensure  the  approxmiation  of  the  muscles.  The  retractor 
should  be  removed  before  these  sutures  are  tied  (Fig.  58). 
After  tying  the  sutures  the  vaginal  wound  is  closed  by  super- 
ficial sutures.  The  result  is,  the  levator  muscles  are  brought 
in  front  of  the  rectum,  thus  effectually  preventing  the  re- 
formation of  rectocele  and  overcoming  the  tendency  to  pro- 
lapse.    The  ease  with  which  the  bowels  can  be  evacuated 


142 


CARE  OF  GYNECOLOGIC  PATIENTS 


is  enhanced.  This  procedure  brings  the  posterior  segnient 
of  the  pelvic  floor  in  contact  with  the  anterior  and  sup- 
ports it.  In  cases  where  there  is  a  weakened  condition  of 
the  upjKT  vaginal  floor,  and  the  j)eritoneum  has  been  pushed 
dow^n  between  the  rectum  and  vagina,  tight  lacing  or  con- 
stipation may  lead  to  a  protrusion  or  hernia  of  the  upper 
vagina,  which  will  cause  the  patient  to  feel  the  rectocele  is 


Fig.  58. — Rectovaginal  interposition  of  the  levator  ani  muscles. 

recurring.  Where  such  a  condition  is  possible,  it  is  wise  to 
cut  through  the  vaginal  wall,  push  back  the  peritoneum,  and 
make  a  wider  approximation  of  the  levators.  The  cicatriza- 
tion thus  produced  is  the  most  effective  resistance  to  further 
trouble. 

Complete  Laceration.  In  this  form  of  laceration  the 
most  important  consideration  is  the  restoration  of  the  func- 
tion of  the  sphincter  (Fig.  59).     The  Bland  retractor  should 


PERINEORRHAPHY;   POSTERIOR  COLPORRHAPHY         143 


Fig.  5g. — Complete  laceration  associated  with  cystocele. 


Fig.  60. — Suture  of  the  ends  of  the  sphincter  muscle. 


144 


CARE  OF  GYNECOLOGIC  PATIENTS 


be  placed  with  a  point  at  the  extremity  of  the  tear  at  cither 
side,  and  will  thus  render  tense  the  line  of  the  septum,  which 
should  be  split  and  anterior  and  posterior  flaps  formed. 
The  posterior  flaps  are  sutured,  preferably  by  the  Lauenstein 
suture,  to  form  the  anterior  wall  of  the  rectum.     The  ends 


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Fig.  6i. — Operation  completed. 


> 


of  the  torn  sphincter  which  have  been  exposed  by  the  dissec- 
tion are  united  by  two  chromic  catgul  sutures  (Fig.  60), 
and  then  the  levator  ani  muscles  and  the  vaginal  wall  and 
skin  surfaces  united,  as  in  the  previous  operation  (Fig.  61). 
The  surface  should  be  cleansed  with  alcohol  and  water  and 
the  line  of  incision  painted  with  the  diluted  iodin.     A  sterile 


PERINEORRHAPHY;  POSTERIOR  COLPORRHAPHY         145 

pad  should  be  kept  over  the  vulva  and  the  surface  irrigated 
after  the  evacuation  of  the  urine,  and  particularly  when  the 
bowels  have  been  moved. 

The  procedures  described  present  the  principal  operative 
measures  performed  upon  and  through  the  vagina,  and 
afford  the  principles  which  should  govern  any  operation  on 
this  tract. 


INDEX 


Abdominal  hysterectomy.  77 

operations,  62 

pain  and  tenderness,  48 
After-care,  29 
Amputation  of  cervix,  123 
Anastomosis,  intestinal,  82 
Anterior  colporrhaphy,  128 

gastro-enterostomy,  92 

Catheterization,  32 
Cervix,  amputation  of,  1 23 

repair  of,  119 
Cholecystectomy,  100 
Cholecystocol ostomy,  loi 
Cholecystoduodenostomy,  101 
Cholecystogastrostomy  ,101 
Cholecysto-ileostomy  ,101 
Cholecystojejunostomy.  loi 
Cholecystostomy,  loc 
Cholecystotomy,  100 
Choledochectom}',  100 
Choledochoplasty,  loi 
Choledochostomy,  100 
Choledocbotomy,  100 
Colporrhaphy,  anterior,  128 

f)Osterior,  138 
Curetment,  116 

Depilatory,  12 
Dilatation,  116 

Drainage,  24 
Dressings,  25 


Fecal  fistula,  60 
Field,  preparation  of,  12 
Fistula,  fecal,  60 

Gall-bl.vdder  operations,  07 
Gastrectomy,  partial,  q6 
Gastric  operations,  86 
Gastroduodenostomy,  96 
Gastro-enterostomy,  anterior,  92 

posterior,  94 
Gastro-gastrostomy,  96 
Gastropexy,  87 
Gastrotomy,  91 

Hemorrhage,  42 
Hypodermoclysis,  40 
Hysterectomy,  abdominal,  77 

subtotal,  77 

vaginal,  132 

Ileus,  58 

Incision,  15 
median,  17 
Pfannenstiel,  19 

Instruments,  16 

for  amputation  of  cervix,  124 
for  anterior  colporrhaphy,  1 20 
for  dilatation  and  curetment.  1 1 7 
for  gastrotomy,  9 1 
for  hysterectomy,  abdominal,  78 

vaginal,  133 
for  intestinal  anastomosis,  83 
for  intravenous  injection,  39 

147 


148 


INDEX 


Instruments   for  operations  on  Fallo- 
pian tube,  68 
on  gall-bladder,  98 
on  kidney,  106 
on  spleen,  104 
for  ovariotomy,  74 
for  perineal  operations,  139 
for  salpingectomy,  68 
for  shortening  round  ligaments,  63 
for  trachelorrhaphy,  1 20 
Intern,  duties  of,  1 1 
Intestinal  anastomosis,  82 
Intestines,  resection  of,  82 

Kidney  operations,  103 

Laceration,  complete,  of  perineum, 

142 
Levator     ani     muscles,    rectovaginal 

inteqiosition  of,  138 
Ligaments,  round,  shortening  of,  62 

Nausea,  41 
Nephrectomy,  no 
Nephropex}',  108 
Nephrotomy,  109 
Nourishment,  34 
Nurse,  duties  of,  11 

Operations,  after-care,  29 
cervix,  amputation  of,  123 

repair  of,  119 
Fallopian  tube,  67 
gall-bladder,  97 
gastric,  86 
kidney, 105 

renal  tumors,  1 1 1 
levator  ani  muscles,  138 
ligaments,  shortening  of,  62 

Montgomery's  modification,  62 


Operations,  ovary,  67 

pelvic  floor,  138 

perineum,    complete    laceration   of, 
142 

spleen,  103 

uterus,  77-132 

dilatation  and  curetment,  116 

vaginal,  114 

Watkins',  130 
Ovariotomy,  73 

Pain,  abdominal,  48 
Panhysterectomy,  77,  80 
Partial  gastrectomy,  96 
Patient,  care  of,  after  operation,  29 
during  operation,  27 
on  admission,  11 
Pelvic  floor,  repair  of,  138 

operations,  62 
Perineorrhaphy,  138 
Perineum,  complete  laceration  of,  142 
Peritonitis,  49 
Phlebitis,  56 
Posterior  colporrhaphy,  138 

gastro-enterostomy,  94 
Pylorectomy,  96 
Pyloroplasty,  96 


Rectovaginal  interposition  of   lc\a- 

tor  ani  muscles,  138 
Round  ligaments,  shortening  cf,  62 

Sai.pinciicctomv,  67 

Salpingo-oophorectomy,  67 

Salpingostomy,  72 

Sepsis,  52 

Shock,  36 

Spleen,  103 

Subtotal  hysterectomy,  77 

Su]iravaginal  hysterectomy,  77 


INDEX 


149 


Tenderness,  abdominal,  48 
Trachelorrhaphy,  119 
Tympanites,  45 

Uterus,  dilatation  and  curetment  of, 
116 
vesicovaginal  interposition  of,  130 


Vaginal  hysterectomy,  129 

operations,  114 
Vomiting,  41 


Watkins'  operation,  130 
Wound,  closure  of,  21 


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s.-ic'XD/':a'S'  books  on 


Musser    and    Kelly    on 
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A  Handbook  of  Practical  Treatment.  By  82  eminent 
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Kelly,  M.  D.,  University  of  Pennsylvania.  Three  octavo  vol- 
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THE  TREATMENT  THAT  IS  ALL  TREATMENT 

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The  Medical  Record 


one 

and  written  with  that  fulness  of  detail  demanded  by  the  every-day  needs  of  the  practi 


Thomson's  Clinical  Medicine 

Clinical  Medicine.  By  William  Hanna  Thomson,  M.D., 
LL.  D.,  formerly  Professor  of  the  Practice  of  Medicine  and  of 
Diseases  of  the  Nervous  System,  New  York  University  Medical 
College.  Octavo  of  667  pages.  Cloth,  $5.00  net;  Half  Moroc- 
co, $6.50  net. 

A  RECORD  OF  50  YEARS 

This  new  work  rejiresents  over  a  Iialf  century  of  active  practice  and  teach- 
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diseases  of  particular  organs  and  tissues.  An  important  chajiter  is  that  on  the 
mechanism  of  surface  chill  and  ''catching  cokl,"  going  very  clearly  into  the 
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diseases  of  special  organs  or  tissues,  every  disease  being  fully  presented  from 
the  clinical  side. 


PRACTICE  OF  MEDICINE 


Tousey's  Medical  Electricity, 
R6nt£(en   Rays,  and   Radium 

Medical   Electricity,  Rontgen    Rays,  and  Radium.     By 

Sinclair  Tousey,  M.  D.,  Consulting  Surgeon  to  St.  Bar- 
tholomew's Hospital,  New  York.  Octavo  of  12 19  pages,  with 
801  illustrations,  19  in  colors.  Cloth,  ;^7.5o  net;  Half 
Morocco,  ^9.00  net. 

NEW  (2d)  EDITION.  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased 
the  size  of  the  book  by  some  100  pages.  About  50  new  illustrations  have  been 
added.  The  new  matter  added  includes  :  Diathermy,  sinusoidal  currents 
radiography  with  intensifying  screens,  rontgenotherapy,  the  Coolidge  and 
similar  Rontgen  tubes  and  the  author's  method  of  dosage,  and  radium  therapy. 
The  book  has  been  enriched  by  including  several  of  Machado's  tabular 
classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  jr-rays,  and 
radium  in  medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing 
is  omitted.  It  tells  you  how  to  equip  your  office,  and,  more  than  that,  how  to 
use  your  apparatus,  explaining  away  all  difficulties.  It  tells  you  just  how  to 
apply  these  measures  in  the  treatment  of  disease.  The  chapters  on  denial 
radiography  are  particularly  valuable  to  those  interested  in  dental  work. 


Abbott's  Medical  Electricity 

Medical  Electricity.  By  George  Knapp  Abbott, 
M.  D. ,  Dean  and  Professor  of  Physiologic  Therapy  and 
Practice,  College  of  Medical  Evangelists,  Loma  Linda,  Cali- 
fornia.    121110  of  132  pages,  illustrated.     Cloth,  $1.25  net. 

This  new  work  gives  the  nurse  the  essentials  of  this  subject.     Dr. 
Abbott's  style  has  made  the  difficult  simple.     The  text  is  illustrated. 


SAUXDENS'  BOOK'S  ON 


Gant's  Work  on  Diarrhea 

Diarrhea,  Inflammatory  and  Parasitic  Diseases  of  the 
Qastro=intestinal  Tract,  By  Samuel  G.  Gant,  INI.  I).,  LL.D., 
Professor  of  Diseases  of  the  Sigmoid  Flexure,  Colon,  Rectum, 
and  Anus,  New  York  Post-Graduate  Medical  School  and  Hospital. 
Octavo  of  604  pages,  with  181  illustrations.      C'loth,  $6.00  net; 

Half  Morocco,  $7.50  net. 

ILLUSTRATED 

This  new  work  i.s  particularly  full  on  the  two  practical  phases  of  the  subject 
— diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic 
points  are  given  under  each  disease,  a  fuller  description  of  diagnostic  methods 
is  given  in  a  special  chapter.  The  differential  diagnosis  of  diarrheas  of  local 
and  those  of  systematic  disturbances  is  strongly  brought  out.  There  is  a 
special  chajiter  on  nervous  diarrheas  and  those  originating  from  gastrogenie 
and  entetogenic  dyspepsias.  You  get  the  psychotherapy  of  psychic  diarrheas. 
You  get  reliable  methods  of  simultaneously  controlling  associated  constipation 
and  diarrhea.  You  get  a  coynxXtiQ  formulary — prescriptions  from  Dr.  Gant's 
own  jiractice.  There  is  a  chapter  on  hookworms,  tapeworms  and  round 
worms,  and  on  the  diarrheas  caused  by  them  and  other  jiarasites.  This  chap- 
ter contains  many  excellent  illustratio"s.  The  limitations  of  drugs  are  pointed 
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intervention  given.  You  get  the  tcchnic  in  detail  of  all  surgical  procedures 
indicated — fully  illustrated. 


Gant's  Intestinal  Stasis  (Constipation  and  Obstruction) 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  lat- 
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personal  experience.  You  get  practical  articles  on  diverticulitis,  peri- 
diverticulitis, pericolitis,  perisigmoiditis  [Jackson's  membrane^.  Lane's 
kink,  and  affections  of  the  ileocecal  valve. 

Octavo  of  57S  pages,  with  250  illustrations.  By  Samuel  G.  (jant,  M.  D.,  LL.  D., 
New  York  Post-Graduate  Medical  School  and  Hospital.  Cloth,  g6.oo  net ;  Half 
Morocco,  87.50  net. 

'•The  best  and  most  complete  treatise  on  these  subjects." — Medical 
Record. 


DIAGNOSIS  AND    TREATMENl- 


Cabot's  Differential  Diagnosis 

Differential  Diagnosis.  Presented  through  an  analysis  of 
385  Cases.  By  Richard  C.  Cabot,  M.D.,  Assistant  Professor  of 
Clinical  Medicine,  Harvard  Medical  School.     Two  octavos  of 

750  pages  each,  illustrated.     Per  volume  :  Cloth,  $5.50  net;  Half 
Morocco,  $7.00  net. 

VOLUME  I  [New  (3d)  Edition — Just  Out]  :  Headache,  pain  in  various 
regions,  fevers,  cliills,  coma,  convulsions,  weakness,  cough,  vomiting,  hema- 
turia, dyspnea,  jauniHce,  and  nervousness — 21  symptoms  and  3S5  cases. 

VOLUME  2  (Just  Out):  .\bdominal  and  other  tumors,  vertigo,  diarrliea, 
dyspepsia,  hematemesis,  enlarged  glands,  blood  in  stools,  swelling  of  face, 
hemoptysis,  edema  of  legs,  frequent  micturition  and  polyuria,  fainting,  hoarse- 
ness, pallor,  swelling  of  arm,  delirium,  palpitation  and  arliythmia,  tremor, 
ascites  and  abdominal  enlargement— 19  symptoms  and  317  cases. 


Morrow's  Diagnostic  and 
Therapeutic   Technic 

Diagnostic  and  Therapeutic  Technic.  By  Albert  S. 
Morrow,  M.D..  Adjunct  Professor  of  Surgery,  New  York  Poly- 
clinic. Octavo  of  830  ])ages,  with  860  original  line  drawings. 
Cloth,  $5.00  net. 

NEW  (2d)  EDITION!^ 

Dr.  Morrow's  new  edition  is  decidedly  a  work  for  you — the  physician  en- 
gaged in  general  practice.  It  is  a  work  you  need  because  it  tell^  you  just 
how  to  perform  tho^e  procedures  required  of  you  every  day,  and  it  tells  you 
and  shinvs  you  by  clear,  wrry  line-drawings,  in  a  way  never  before  approached. 
The  iiifornialion  it  gives  is  such  as  you  need  to  know  every  day — transfusion 
and  infusion,  hypodermic  medication,  Bier's  hyperemia,  exploratory  \>\\\\c. 
tures,  aspirations,  anesthesia,  etc. 

Journal  American   Medical  Association 

"   1  he   procedures  lie^cnljcd  ^re   tliose  which   practitioners   may  at  some  time  be  called 
on  to  perform.  " 


SAUNDERS'  BOOKS  ON 


Garrison's  History  of  Medicine 

History  of  Medicine.  ^Vith  Medical  Chronology,  Biblio- 
graphic Data,  and  Test  Questions.  By  Fielding  H.  Garrison, 
M.  D. ,  Principal  Assistant  Librarian,  Surgeon-General's  Office, 
^^'ashington,  D.  C.  Octavo  of  763  pages,  illustrated.  Cloth, 
$6.00  net ;  Half  Morocco,  ^7.50  net. 

THE  BAEDEKER  OF  MEDICAL  HISTORY 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in 
a  most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  (ireek  medicine,  the  Byzantine  period;  the  Moliamme- 
dan  and  Jewish  periuds,  the  Medieval  period,  the  period  of  the  Renaissance, 
the  Revival  of  learninij  and  the  Reformation  ;  the  Seventeenth  Century  (the 
age  of  individual  scientific  endeavor),  the  Eighteenth  Century  (the  age  of 
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vancement of  science),  the  Twentieth  Century  (the  beginning  of  organized 
preventive  medicine).  You  get  all  the  important  facts  in  medical  history;  a 
biographic  (/itrliona ty  o{\.he  makers  of  medical  history,  arranged  alphabetically; 
an  album  of  tnedical  portraits;  a  complete  medical  chro^iology  (data  on  dis- 
eases, drugs,  operations,  etc.);  a  brief  survey  of  the  social  and  cultural  phases 
of  each  period. 


McKenzIe  on  Exercise      |Z' 

Exercise  in  Education  and  Medicine.  By  R.  Tait 
McKknzir,  B.  a.,  M.  I).,  Professor  of  Physical  Education,  and 
Director  of  the  Department,  University  of  Pennsylvania.  Oc- 
tavo of  585  pages,  with  478  illustrations.      Cloth,  $4.00  net. 

D.  A,  Sargent,  M.  D.,  Director  0/  Hetnemvay  Gymnasium,  Harvard  University. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  o( 
an  expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Carter's  Diet  Lists 

DiKT    IJST.S  OK  THE    PkESPYTF.RIAN  HOSPITAL  OF    NeW    VoRK  CiTY. 

Compiled,  with  notes,  by  Herbert  S.  Carter,   M.  D.     i2mo  of  129 
pages.      Cloth,  ^i.oo  net. 

Bonney's  Tuberculosis  second  Edi«on 

Tuherlui.osis.  By  Sherman  G.  Bonney,  M.  D.,  Professor  of 
Medicine,  Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages, 
with  243  illustrations.     Cloth,  $7.00  net ;  Half  Morocco,  ^8.50  net. 


THE    PRACTICE    OF   MEDICINE 


Anders' 
Practice    of    Medicine 

A  Text=Book  of   the    Practice   of   Medicine.     By  James 

M.  Anders,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice 
of  Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  Col- 
lege, Philadelphia.  Handsome  octavo,  1332  pages,  fully  illus- 
trated.    Cloth,  ^5.50  net ;  Half  Morocco,  ^7.00  net. 

NEW  (12th)   EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration 
given  to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of 
distinction  of  simulating  diseases  being  presented  in  tabular  form.  In  this 
new  edition  Dr.  Anders  has  included  all  the  most  important  advances  in 
medicine,  keeping  the  book  within  bounds  by  a  judicious  elimination  of 
olisolete  matter.      A  great  many  articles  have  also  been  rewritten. 

Wm.   E.  Quine,   M.  D.,    College  of  Physicians  and  Surgeons,  Chicago. 

"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession 
at  this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's   Physical  Diag'nosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  Asso- 
ciate Professor  of  Medicine,  Jefferson  Medical  College.  Octavo 
of  589  pages,  with  original  illustrations.     Cloth,  $3.50  net. 

NEW  (3d)  EDITION 

In  Dr.  DaCosta's  work  every  method  given  has  been  carefully  tested  and 
proved  of  value  by  the  author  himself.  Normal  physical  signs  are  explained 
in  detail  in  order  to  aid  the  diagnostician  in  determining  the  abnormal.  Both 
direct  and  differential  diagnoses  are  emphasized.  The  243  original  illustra- 
tions are  artistic  as  well  as  practical. 

Henry  L.   EUner,    M.  D.,    Professor  of  Medicine,  Syracuse  University. 

"  I  have  reviewed  this  book  and  am  thoroughly  convinced  that  it  is  one  of  the  best 
ever  written  on  the  subject.     In  every  way  I  findit  a  superior  production." 


SAUXDE/iS'    BOOKS   OiV 


Sahli's  Diag[nostic  Methods 

Edited  by  N&th'l  Bowditch  Potter.    M.D. 


A  Treatise  on  Diagnostic  Methods  of   Examination. 

By  Prof.  Ur.  H.  Sahii,  of  Bern.  Edited,  with  additions,  by 
Nath'l  Bowditch  Potter,  M.D.,  Assistant  Professor  of  Clinical 
Medicine,  Columbia  University.  Octavo  of  1225  pages,  pro- 
fusely illustrated.     Cloth,  $6.50  net. 

SECOND  EDITION.  RESET 
Lewellys  F.  Barker,  M.  D. 

I'ti'/cssor  of  Midkiiw.  Johns  I lopliins  University 
"  I  am  delighted  with  it.  and  it  will  be  a  pleasure   to  recuinmend   it  to  our  students  in 
the  Johns  Hopkins  Medical  School." 


Friedenwald  6  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald, 
M.  D.,  Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah, 
M.  D.,  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.   Octavo  of  85  7  pages.     Cloth,  ^4.00  net. 

NEW  (4th)  EDITION 

Dietetic  m.inagement  in  nil  diseases  in  wliich  diet  plays  a  part  in  treat- 
ment is  carefully  considered,  the  articles  on  diet  in  diseases  of  ilie  digestive 
organs  containing  numerous  diet  lists  and  explicit  in.struciions  for  adtninistra- 
tion.  The  feeding  of  infants  and  children,  of  patients  before  and  after  anes- 
thesia and  surgical  operations,  are  all  taken  up  in  detail. 

"  It  seems  to  rae  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  avail- 
able. I  am  especially  glad  to  see  the  long  list  of  ;inalyses  of  different  kinds  of  food." — 
Geor(;k  Dock,  M.  D.,  Ttilane  Unii'ersitv  of  Louisiana. 


Eggleston*s  Prescription  Writing 


This  new  work  is  a  crystallization  of  Dr.  Eggleston's  long  experience 
in  teaching  tliis  subject.  It  covers  the  entire  field  in  a  most  practical  way, 
taking  u|i  grammar,  construction,  dosage,  vehicles,  incompatibility,  ad- 
ministration, etc. 

i6mo  of  115  pages.      By  Gary  Egolrston,   M.  D  ,  Instructor  in  Pharmacology  at 
Cornell  Utiiveisity  Medical  School.     Cloth   ;Ji.oo  net. 


PRACTICE  OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and   Pancreas 

Diseases  of   the   Stomach,   Intestines,    and    Pancreas. 

By  Robert  Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intes- 
tinal  Diseases  at  the  New  York  School  of  CHnical  Medicine. 
Octavo  of  1025  pages,  with  377  illustrations.  Cloth,  $6.50  net; 
Half  Morocco,  $8.00  net. 

NEW  (2d)  EDITION 

It  is  the  practitioner  wlio  first  meets  wiih  these  cases,  and  it  is  he  upon 
whom  the  burden  of  diagnosis  rests.  After  tlie  diagnosis  is  established,  tlie 
practitioner,  if  properly  equipped,  could  frequently  treat  the  case  himself 
instead  of  transferring  it  to  a  specialist.  This  work  is  intended  to  equip  the 
practitioner  vvitli  this  en<l  in  view. 

The  Therapeutic  Gazette 

"  The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and 
chemical  examination  are  adequately  and  correctly  described." 


Oastedo's  Materia  Medica,  Pharmacology, 
Therapeutics,  and     Prescription     AVriting 

By  W.  A.  Bastedo,  M.  D.,  Associate  in  Pharmacology  and 
Therapeutics  at  Columbia  University.  Octavo  of  602  pages, 
illustrated.  Cloth,  $3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  B.tstedo's  new  work  has  the  distinct  advantage  of  presenting  the 
subjects  from  both  the  laboratory  and  the  clinical  sides.  Dr.  Bastedo  for 
many  years  devoted  his  entire  time  to  laboratory  work.  Now,  however,  he 
is  strictly  a  clinical  m?i\\.  He  gives  you  the  practical,  daily  application  of  that 
information  he  gleaned  at  first  hand  in  the  laboratory — facts  vou  can  use  ir. 
your  bedside  practice.  Because  of  this  early  laboratory  training  you  are 
assured  that  his  book  is  correct  according  to  laboratory  statuiards.  Being 
now  a  strictly  clinical  man,  you  know  that  his  book  is  modeled  with  the  common 
purpose  of  all  medical  practice  :    The  treatment  of  the  sick. 


lo  SAUNDERS'    BOOKS    ON 

Faug'ht's   Blood-Pressure 

Blood=Pressure    from    the    Clinical    Standpoint.      By 

Francis  A.  Fauiiht,  M.  I).,  formerly  Director  of  the  Laboratory 
of  Clinical  Medicine  of  the  Medico-Chirurgical  College  of  Phila- 
delphia.    Octavo  of  475  pages,  illustrated. 

NEW  (2d)   EDITION 

Dr.  Faught'.s  book  is  designed  for  practical  help  at  the  beihide.  It  meets 
the  urgent  needs  of  the  general  practitioner,  who  heretofore  liad  no  book  to 
which  to  turn  in  case  of  emergency.  Every  effort  has  been  made  to  provide 
here  a  practical  guide,  full  of  information  of  a  clinical  nature,  and  presented 
in  a  way  readily  available  for  daily  use  by  the  busy  man.  Besides  the  actual 
technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The 
[iractical  apjilication  of  sphygmomanometric  findings  within  recent  years  makes 
it  imperative  for  every  medical  man  to  have  close  at  hand  an  up-to-date  work 
on  this  subject, 

Anders  and  Boston's  Medical 

Diagnosis 

A  Text-Book  of  Medical  Diagnosis.  By  James  M.  An- 
ders, M.D.,  Ph.D.,  LL.  D.,  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine,  and  L.  Napoleon 
Boston,  M.  D.,  Professor  of  Physical  Diagnosis,  Medico-Chirur- 
gical College,  Philadelphia.  Octavo  of  1248  pages,  with  466 
illustrations.     Cloth,  ^6.00  net. 

NEW  (2d)   EDITION 

This  new  worl<  is  designed  expressly  for  the  general  practitionei.  The 
metlmds  given  are  practical  and  especially  adajited  tor  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  dohnite  Way  by  men  who  have 
hail  wide  e.xperiince  at  the  bedside  and  in  tlu-  clinical  laboratory. 

The  Medical  Record 

"  1  In:  assfici.itioii  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  labora- 
tory worker  is  mcjst  tortunate.      It  must  long  occupy  a  pre-eminent  position." 


PRACTICE  OF  MEDICINE  u 


Deaderick  ^  Thompson's  Endemic  Diseases  of  South 

Endemic  Diseases  of  the  Southern  States.  By  William 
H.  Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Association  of 
Immunologists.  Octavo  of  546  i)ages,  illustrated.  Cloth,  ^^5.00  net ; 
Half  Morocco,  %ii.^o  net. 

This  new  work  is  really  a  collection  of  monographs  on  malaria,  blackwater  fever, 
pellagra,  amebic  dysentery,  hookworm  disease,  and  other  intestinal  parasites. 
Diagnosis,  prophylaxis,  and  treatment  are  gone  into  in  detail,  giving  you  every  aid  to 
the  correct  interpretation  of  the  symptoms  presented,  and  every  modern  means  of 
value  in  the  prevention  and  treatment  of  the  diseases  discussed. 


Smith's  What  to  Eat  and  Why  Second  Edition 

What  to  Eat  and  Why.  By  G.  Carroll  Smith,  M.  D.,  Boston. 
l2mo  of  377  pages.     Cloth,  ;5S2.5o  net. 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be  dieted — 
you  will  be  able  to  prescribe  the  suitable  diet  yourself,  just  as  you  do  other  forms  of 
therapy.  Dr.  Smith  gives  'the  why"  of  each  statement  he  makes.  It  is  this  knowing 
why  which  gives  you  confidence  in  the  book,  which  makes  you  feel  that  Dr.  Smith 
knoxvs. 


Ward's  Bedside  Hematology 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.  D.,  Fellow  of 
the  Royal  Society  of  Medicine,  London,  England.  Octavo  of  394 
pages,  illustrated.      Cloth,  ^3.50  net. 


Slade's  Physical  Examination  d  Diagnostic  Anatomy 

« 

Physical  Examination  and  Diagnostic  Anatomy.  By  Charles 
B.  Slade,  M.  D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital  Medical  College.  i2mo  of  146  pages,  illustrated. 
Cloth,  ^1.25  net. 


12  SAUNDERS'    BOOKS  ON 

Stevens'  Therapeutics  F^^tl^  Edition 

A  Text-Book  ok  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer  on  Physic.il  Diagnosis  in  the 
University  of  Pennsylvania.     Octavo  of  675  pages.      Cloth,  1^3.50  net. 

I)r  Stevens'  'therapeutics  is  one  of  the  must  successful  works  on  the  subject  ever 
published.  In  this  new  edition  the  work  has  undergone  a  very  thorough  revision, 
and  now  represents  the  very  latest  advances. 

The  Medical  Record,   New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  Sixth  Edition 

A  Text-Book  of  Materia  Meuica,  Therapeutics,  and  Ph.-vrma- 
coi.oGY.  By  George  F.  Biti.er,  I'n.Ci.,  M.D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  .Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  ;^4.oo  net;   Half  Morocco,  $5.50  net. 

For  this  si.\th  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part  hav- 
ing been  rewritten.  .411  obsolete  matter  has  been  eliminated,  and  special  attention 
has  been  given  to  the  toxicologic   and  therapeutic  effects  of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omiiied  by  the  author  which,  in  his  judgment,  would  add  to 
the  completeness  of  the  text." 

SoUmann's  Pharmacology  Second  Edition 

A  Text-P>0()K  of  Phakmacoi.ogv.  By  Tor  a  ld  Sollmann,  M.D., 
Professor  of  Pharmacology  and  Materia  Aledica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  ^4.00  net. 

The  author  bases  the  study  of  therapeut'cs  on  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringham,  M,D.,  Trinity  Mfdical  College,   Toronto. 

"The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scien- 
tific a  manner  by  any  other  le.xt  1  have  read  on  the  subjects  embraced." 

Amy's  Pharmaicy 

I'KiNcu'i  Ks  (jf  Pharmacy.  By  Henry  V.  Aknv,  Ph.  C,  Ph.  D., 
Professor  of  Pharmacy,  New  York  College  of  Pharmacy.  Octavo  of 
1 175  pages,  with  246  illustrations.      Cloth,  $5.00  net. 

George  Reimann,  Ph.  G.,  Secretary  of  the  New  York  state  Board  0/  rhartiiacy. 

"  1  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it 
ought  to  be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy.'' 


THERAPEUTICS  AND   MATERIA  MEDIC  A 


Hinsdale's   Hydrotherapy 

Hydrotherapy  :  A  Treatise  on  Hydrotherapy  in  General ; 
Its  Application  to  Special  Affections  ;  the  Technic  or  Processes 
Employed,  and  the  Use  of  Waters  Internally.  By  Guy  Hinsdale, 
M.  D.,  Fellow  of  the  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.       Cloth, $3. 50  net. 

The  Medical  Record 

"  We  cannot  conceive  of  a  work  more  useful  to  the  general  practitioner  than  this,  nor 
one  to  which  he  would  resort  more  frequently  for  reference  and  guidance  in  his  daily 
work." 


Kelly's  Cyclopedia  of  American 
Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  How- 
ard A.  Kelly,  M.  D.,  Johns  Hopkins  University.  Two  octavos 
of  525  pages  each,  with  portraits.  Per  set  :  Cloth,  Sio.oo  net; 
Half  Morocco,  $13.00  net. 

Dr.  Kellv,  in  these  two  handsome  volumes,  ]:ire.-ents  concise,  yet  com- 
plete biographies  of  those  men  and  women  who  have  contributed  notewor- 
thily  to  the  advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for 
painstal<ingcaie  assures  accuracy  of  statement.  There  are  about  one  thousand 
biographies  included. 

Swan's  Prescription-writing  and  Formulary 

Prescription- wRMiNG  and  Formulary.  By  John  M.  Swan, 
M.D.,  Director  Glen  Springs  Sanitarium,  ^Yatkins,  N.  Y.      I2mo  of  185 

pages.      Flexible  cloth,  $1.25  net. 

Stewart's    Pocket    Therapeutics    and    Dose- 
book  New   (4th)  Edition 

Pocket  Therapeutics  and  Dose-book.  By  Morse  Stewart,  Jr., 
M.D.     3 2mo  of  263  pages.      Cloth,  $1.00  net. 

Bohm  and  Painter's  Massage 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  (iermany.  Edited, 
with  an  Introduction,  by  Charles  F.  Painter,  M.D.,  Profe.s.'ior  of 
Orthopedic  Surgery  at  Tufts  College  Medical  School,  Boston.  Octavo 
of  91  pages,  with  97  practical  illustrations.     Cloth,  ;^i.75  net. 


14  SAUNDERS'    BO  OKU    ON 

THE  BEST  ninerican  standard 

Illustrated   Dictionary 

The  New  (8th)    Edition,  Reset 

The  American  Illustrated  Medical  Dictionary.     By  W.  A. 

Newman  Borland,  M.  D.,  Editor  of  "The  American  Pocket 
Medical  Dictionary."  Octavo  of  1 137  pages.  Flexible  leather, 
$4.50  net;  with  thumb  index,  $5.00  net. 

OVER   1500  NEW  WORDS 

Howard   A.    Kelly,    M.  D.,  Johns  Hopkins  University,  Baltimore. 

"  Or.  Dorland's  dictionary  is  admirable.      It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book  Fourth  Edition 

Dose-Book  and  Manual  of   Prescription-Writing.     By  E.  Q. 

Thornton,  M.  D.,  Assistant   Professor  of  Materia    Medica,    Jefferson 

Medical    College,    Philadelphia.       Post-octavo,    392    pages,    illustrated. 

Flexible  leather,  ^2.00  net. 

"  It  will  afford  ine  much  pleasure  to  recommend  the  book  to  my  classes,  who  ofter 
fail  to  find  such  information  in   their   other   text-books." — C.    H.    Miller,   M.D 
Professor  0/  Pharmacology,    Nort/nuestern  University  Medical  School,  Chicago. 

Lusk    on    Nutrition  second  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk, 
Ph.D.,  Professor  of  Physiology  in  Cornell  University  Medical  School. 
Octavo  of  402  pages.     Cloth,  ^3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the 
subject." — Lewbli.vs  F.  Bakkkk,  M.  D.,  Professor  0/  the  Principles  and  Practice 
of  Medicine,  Johns  Hopkins  University. 

Hatcher  and  Sollmann's  Materia  Medica 

A  Text-Book  of  Materia  Medica:  including  Laboratory  Exer- 
cises in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert 
A.  Hatcher,  Ph.  (}.,  M.  D.;  and  Torald  Sollmann,  M.  D.  i2mo 
of  411  pages.     Flexible  leather,  ^2.00  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.  l2mo  of  302 
pages,  illustrated.     Cloth,  $\.^o  net. 


MATERIA  ME  Die  A  A.VD   THERAPEUTICS.  15 

American  Pocket  Dictionary  ^ew  (9th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  M.D.  Flexible  leather,  with  gold  edges,  $1.00 
net ;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Thera- 
peutics AND  Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D., 
and  Eugene  W.  Caldwell,  B.  S.  Octavo  of  625  pages,  with  200 
illustrations.     Cloth,  $5,00  net. 

Cohen   and    Cshner's    Diagnosis.     Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  and  A.  A. 
Eshner,  M.  D.  Post-octavo,  382  pages  ;  55  illustrations.  Cloth,  $1.00 
net.      /;/  Snmiders^  Question- Compend  Series. 

Seventh 

Morris'  Materia  Medica  and  Therapeutics  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescrip- 
tion-Writing. By  Menky  Morris,  M.  D.  Revised  by  W.  A.  Bas- 
TEDO,  M.  D.,  Instructor  in  Materia  Medica  and  Pharmacology,  Columbia 
University.     l2mo,  300  pages.      Cloth,  ^i. 00  net.    Saion/ers'  Coin/'ends. 

Deaderick  on  Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick, 
M.  D.,  Member  American  Society  of  Tropical  Medicine.  Octavo  of 
402  pages,  illustrated.     Cloth,  $4.50  net. 

Goepp's  State  Board  Questions  Third  Edition 

State  Board  Questions  and  Answers.  By  R.  Max  Goepp, 
M.  D-,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Octavo 
of  715  pages.     Cloth,  $4.00  net. 

Niles   on     Pellagra  New  (2d)  Edition 

Pellagra.  By  George  M.  Niles,  M.  D.,  Gastro-enterologist  to 
the  Georgia  Baptist  Hospital,  Atlanta.  Octavo  of  253  pages,  illustrated. 
Cloth,  ;S53.oo  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D,, 
Professor  of  Clinical  Medicine,  Tufts  Medical  College,  Boston.  Single 
charts,  5  cents;  50  charts,  ;^2.oo  net;  500  charts,  ^iS.oo  net;  1000 
charts,  ^30.00  net. 


i6  SAUA'DEHS'    BOOKS    OIV    PRACTICE,    Eh: 


Saunders'   Pocket   Formulary  Ninth  Edition 

Saunders'  Pockkt  Medical  Formulary.  By  William  M. 
Powell,  M.  D.  Containing  1900  formulas  from  the  best-known 
authorities.  In  flexible  leather,  with  side  index,  wallet,  and  flap. 
$1.75  net. 

Jakob  and  £shner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Mkdiltnk  and  Clinical  Diac;- 
Nosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by 
A.  A.  EsHNKR,  M.  D.  182  colored  figures  on  68  plates,  64  text-cuts, 
259  pages  of  text.     Cloth,  ^3.00  net.      In  Saunc/e/s'  Hand- Atlas  Series. 

Lockwood's  Practice  of  Medicine     Revised^and'^ESarged 

A  Manual  of  the  Practice  of  Medicine,  By  Geo.  Roe  Lock- 
wood,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.     Octavo,  847  pages,  illustrated.     Cloth,  ;^4.oo  net. 

Fenwick's  Dyspepsia 

Dyspepsia.  By  William  Soltau  Fenwick,  M.  D.,  of  London. 
Octavo  of  485  pages,  illustrated.     Cloth,  ^3.00  net. 

Jelliffe's   Pharmacognosy 

An  Introduction  to  Pharmacognosy.  By  Smiih  Ely  Jelliffe, 
Ph.  D.,  M.  D.,  Columbia  University,  New  York.  Octavo  of  265  pages, 
illustrated.      Cloth,  ^2.50  net. 

Stevens'   Practice   of   Medicine  New  (lOth)  Edition 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Professor  of  Therapeutics  and  Clinical  Medicine,  Woman's 
Medical  College,  Philadelphia.  l2mo,  573  p^iges,  illustrated.  Flexible 
leather,  $2. 50  net. 

Camac's  Epoch=Making  Contributions 

Epoch-making  Contributions  to  Medicine  and  Surgery.  By 
C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages, 
with  p(  rtraits.     Artistically  bound,  j^4.oo  net. 

Todd's  Clinical  Diagnosis  New  (3d)  Edition 

Clinical  D.Ar.Nosis.  By  James  Campiucli.  Toi.n,  MD  Professor 
of  Pathologv,  University  of  Colorado.  Denver.  l2mo  of  585  pages, 
illustrated.     Cloth,  $2.50  net. 


15  '^ 


OCT  2  11988 


